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Research & Reports

Searching in Biopharma (1575)

Accountable Care Organizations: How Will Payer and Provider Adoption of This Model Impact Prescribing Trends in Cardiometabolic Diseases?

ACOs grew out of various pilot projects that seek to tie provider reimbursement to patient outcomes, cost, and patient satisfaction. Although the formal ACO is a Medicare project, payers and providers are rapidly developing ACO-type models for commercially insured beneficiaries. These models range in complexity and risk from a fee-for service model (with shared savings) to a capitation model that leaves physicians with downside financial risk if costs increase or quality worsens. If successful, ACOs will be responsible for millions of patients and will have a powerful impact on prescribing behaviour.

Questions Answered in This Report:

  • Who is Establishing ACO-type Models and How? What percentage of physicians are currently part of an ACO and what percentage expect to join an ACO in 12 months’ time? What kinds of insurers are developing them for their commercial populations? Are they available for self-funded members, fully insured members or both? What indications are being targeted as part of ACOs, now and in 12 months’ time? What kind of physicians/physician groups are joining the ACOs? How are beneficiaries being identified and persuaded to join an ACO? What are MCOs’ goals for their ACO contracts?

  • How Will ACOs Impact Prescribing Behavior? What performance and efficacy measurements are payers using to determine bonus payments to physicians and hospitals? How are these likely to impact prescribing behaviour in cardiometabolic treatment? How will financial incentives influence physician prescribing of brands versus generics?  How would MCO PDs like the pharmaceutical industry to partner with them in the context of ACO contracting?

  • How Are ACOs Treating Prescription Drugs? Which formularies are ACOs following, now and in 12 months’ time? What is the difference between an ACO formulary and traditional formulary in terms of coverage of specific branded and generic drugs for cardiovascular disease and diabetes? How are ACOs favoring specific brands? Is prescription drug spending included in the ACO cost measurements? How is that influencing prescribing behaviour for specific branded and generic drugs for cardiovascular disease and diabetes? How do payers expect ACOs to impact medical costs and prescription drug costs? What are payers measuring as part of ACOs, including HbA1c screenings and medication possession ratios?

Scope:

This U.S. Physician and Payer Forum explores how the development and launch of payer-provider contracting arrangements known as ‘Accountable Care Organizations’ are affecting brand prescribing. Analysis is based on a survey of 140 prescribers (primary care physicians and endocrinologists) and 25 pharmacy and medical directors at MCOs that currently contract with an ACO-type structure, or plan to do so within the next 12 months. By understanding how the development of ACOs will impact prescribing behavior, drug developers can begin to identify how to leverage these programs to favor, or at least protect their brands. We focus on cardiovascular and metabolic conditions—the areas that will see the greatest emphasis over the next year.