Medical Directors Anticipate ACOs Will Have Moderate Impact on Specialty Medications

ACO focus on efficiency and quality metrics rather than pharmaceutical access cited in new survey.

Accountable care organizations (ACOs) are not expected to have a drastic impact on managing specialty medications or biopharmaceuticals, according to new research published in the March 2014 edition of the Journal of Managed Care Medicine.

Most participants thought ACOs would have a moderate impact on managing new pharmaceuticals, which researchers attributed to ACOs’ focus on efficiency and more general quality metrics rather than on pharmaceutical access.

In addition to ACOs, participants expected comparative effectiveness research, clinical pathways, and revised formulary structure or models to have the most influence on managed care involving biopharmaceuticals.

Researchers sent the survey to a random sample of medical director members of the National Association of Managed Care Physicians, and received 40 responses. Most of the respondents—70%—were medical directors of commercial managed care organizations, and the remaining 30% identified themselves as medical directors of health systems, academic medical centers, hospital and other health systems, or large physician practices.

Researchers also included decision makers from leading managed care organizations, including Aetna, Cigna, WellPoint, and United Healthcare. Researchers used input from the Genomics, Biotech, and Emerging Medical Technologies Institute (GBEMTI) Executive Leadership Council to supplement survey findings, as well as to add additional perspective, researchers noted.

The technologies expected to impact care quality and cost were vaccines, small molecule medications, and biologics, the results showed. Participants also viewed cell and gene therapies favorably, but were not as convinced about nanotechnology.

Most participants felt risk sharing, comparative effectiveness research, and health information technology would have a greater impact on care quality and cost. Despite this, ACOs, value-based purchasing, and coverage with evidence development ranked only slightly below the 3 leaders in terms of potential impact.

Meanwhile, participants felt that the most likely health technology outcomes from introducing ACOs would be scrutiny of value, clinical pathways, and new contracting requirements. Preclusion of certain new health technologies, and carve outs for certain technology assessments, were not believed to be as likely to be used in the ACO environment, which the authors believe suggests an emphasis on strategies that demonstrate value to payers.

Medical home programs were also identified as an important part of ACO models, providing that any incentives in the structure rewarded cost-effective and responsible care decisions in a way that is timely and does not impede care access.

Although GBEMTI’s Executive Leadership Council indicated that the ACO model’s implications on biopharmaceuticals are unclear, most said management approaches would not single out the therapies specifically. Recurring themes regarding therapy management included tightening prior authorizations, developing and enforcing clinical pathways, engaging providers to enhance care consistency around the pathways, and providing incentives that support use of lower cost or high-value alternative therapies.

Most participants—80%—expect ACOs’ built-in quality measures and performance-based provider dashboards to reduce health care costs significantly. Despite this finding, researchers could not determine a primary savings driver from their results, which they attributed to shortcomings within existing metrics.

The ACO model’s success in the area of biologic therapy hinges on the same principle guiding its overall success, the researchers noted.

“If the ACO model becomes the dominant system for payment for health care in the US, patients will have to become better informed consumers of health care,” the researchers wrote. “. . . This would include consumers developing an informed perspective on the benefits and risks associated with particular treatment choice decisions, particularly those for which the patient has a significant financial stake in the decision. Because of this, channeling information on the comparative value to treatment alternatives will need to extend beyond focus on payers and providers to include the patient.”