Market Outlook

This report examines the market access factors that influence the success of therapies for chronic heart failure (CHF), with a special focus on payers’ and cardiologists’ reactions to the trend in outcomes-based contracts (OBCs). OBCs require pharmaceutical manufacturers to justify the use of expensive new therapies. Novartis, for example, entered into OBCs with several managed care organizations (MCOs) for its heart failure drug Entresto. We asked MCO pharmacy and medical directors about their experience with OBCs and cardiologists about their involvement in such contracts.

Questions Answered:

  • Are MCOs embracing risk-based contracting strategies for cardiology drugs and Entresto in particular? What is the outlook for this strategy for emerging heart failure therapies?
  • What are the results, if any, of MCOs’ OBCs for Entresto? What performance benchmarks are most important in an OBC for heart failure drugs?
  • How do OBCs affect cardiologists’ prescribing decisions? How will MCOs approach the coverage of drugs that will be indicated for heart failure with preserved ejection fraction (HFpEF)?

Table of contents

  • Heart Failure - Access & Reimbursement - Detailed, Expanded Analysis (US): Chronic Heart Failure: Special Focus On Outcomes-Based Contracting
    • U.S. A&R Chronic Heart Failure: Special Focus on Outcomes-Based Contracting

Author(s): Stephanie Hoops; Chris Lewis

Stephanie Hoops serves as market analyst responsible for providing state health plan analyses for Michigan, Missouri, Arkansas, North Dakota and Kansas. Her work involves an examination of trends surrounding managed care, pharmacy benefits, accountable care organizations, Medicare Advantage and Medicaid in each state. She also provides analyses concerning health systems and hospitals, physician groups, managed care organizations, legislation and other trends for the Sacramento, Kansas City, Little Rock and Portland metropolitan statistical areas.

Hoops worked as a newspaper reporter for 15 years prior to joining DRG in 2015. During her time in journalism she earned numerous accolades, including a first-place breaking news award from the Society of American Business Editors and Writers. In addition to being a seasoned journalist, Hoops is a licensed attorney. She holds degrees from Northwestern University (MSJ), the University of Michigan (BMA) and Michigan State University College of Law (JD).

Chris Lewis serves as primary research manager, U.S. Access and Reimbursement, with responsibility for coordination, content review and content generation of the market access and reimbursement insights at DRG. Content is based on online surveys of managed care organizations and physicians and expert analysis of reimbursement and prescribing patterns of key therapies treating various disease states.

Lewis was an analyst/senior analyst for the group’s HealthLeaders-InterStudy subsidiary for eight years, specializing in the managed care and pharmacy benefit management industries. Throughout her tenure, she has produced the Health Plan Analysis reports for California, New York, New Jersey, Connecticut, and Pennsylvania and authored DRG’s series of pharmacy benefit manager profiles. She has also conducted numerous webinars for the group. She is a seasoned journalist with a B.A. in communications from California State University, Sacramento.

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