Market Access

71% of surveyed MCOs have outcomes-based contracts with pharma or plan to by the end of 2019

Outcomes-based contracting (OBC) is a growing value-based purchasing strategy used by U.S. healthcare payers to hold pharmaceutical companies responsible for ensuring that their drugs perform according to expectations in a real-world patient setting. Key finding: OBCs are increasingly embraced by payers, with 71% of surveyed pharmacy and medical directors from managed care organizations (MCOs) reporting […]

Top Seven Predictions for PBM industry in 2019

While 2018 was a busy year for pharmacy benefit managers making waves, 2019 looks no different. Vertical integration will undoubtedly remain the key driver for transformation as both the mega-mergers of CVS/Aetna and Cigna/Express Scripts are now completed. These combined healthcare powerhouses are poised to bring some major changes in the outlook of pharmacy benefit […]

Mutual Self-Interest: Joint Venture Payer-Provider Health Plans

As large hospital systems have amassed greater power in their markets through mergers, developing regional integrated delivery networks and starting ACOs, health plans and providers have had to re-think the old oppositional relationship between payers and providers. The last decade’s evolution of performance-based payments and value-based care, together with the technology and systems that make […]

How Common is In-Office Dispensing of Oral Prostate Cancer Drugs?

The growing trend of physicians dispensing of oral oncolytics directly to patients disrupts the U.S. reimbursement system’s traditional reliance upon insurers’ specialty pharmacies. Key finding:  Three quarters of oncologists and urologists surveyed by DRG reported that their practices have the capability to dispense oral prostate cancer drugs through their practice’s licensed pharmacy (most common) or […]

How Disney is Disrupting Orlando Healthcare

American employers experimenting with direct provider contracts usually do it on a small scale, but Walt Disney World Resorts in Orlando is fully committing with provider HMOs that insure most of the company’s Orlando workforce. With a possible 70,000 Orlandoans receiving care solely from the provider networks of Orlando’s two largest integrated delivery networks, the […]

How are Medical Device Companies Responding to Value-Based Healthcare?

Medical devices are an integral part of the healthcare ecosystem, and any changes to the functioning of this system can have a direct and significant impact on the device industry. A prominent trend in healthcare delivery has been the shift from a traditional fee-for service payment model to a value-based reimbursement model in which physicians, […]

Under ISP, How Will your Plan Assess an Oncology Drug’s Value for an Indication?

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9 Ways Payers May be Impacted by Vertical Integration

The transformation of the healthcare delivery model and the reinvention of the PBMs will have implications for payers – what are the threats and opportunities? The below post is an excerpt from our white paper Beyond the PBM: A New Order for Healthcare Delivery.    Vertical integration giving PBMs a bigger role in the healthcare value […]

IDNs’ Continued Displacement of Traditional Insurers

Partners, Harvard Pilgrim Negotiations Underscore Growing Trend Amid continued merger mania in the U.S. healthcare industry, the news that integrated delivery titan Partners HealthCare is exploring a merger with innovative New England insurer Harvard Pilgrim Health Care stands out. The deal would not only add to a collection of tie-ups that are blurring the industry’s […]

Medicare Advantage leader eyes 50 percent penetration — but when?

Evaluating UnitedHealth’s Managed Medicare Prediction Among the key takeaways from UnitedHealth Group’s first quarter earnings call was a prediction that the market penetration of managed Medicare plans will reach 50 percent, up from roughly one-third today. This is at least the second time in the past year that a UnitedHealth official has staked that claim, […]