Accountable care organizations (ACOs), in which providers are held accountable for the costs of treating a payer’s patent population, will become more the rule than the exception in a year, as providers and payers alike move to accommodate a new payment paradigm that shifts the focus away from pay for quantity to pay for quality and cost-effective care delivery. Acute coronary syndrome (ACS)—which encompasses myocardial infarction and unstable angina—and atrial fibrillation (AF)—the most common sustained arrhythmia—are two conditions that are ripe for ACO-related outcomes and cost improvements. In particular, AF is among the top conditions (along with chronic obstructive pulmonary disease and type 2 diabetes)—that managed care organizations believe represent the best opportunities for ACOs to make a difference for outcomes improvements and cost efficiencies in the ACO. The adoption of the ACO model is spreading from its origins in the Medicare system into the realm of commercial health plans. ACOs are making cardiologists more conscious of the long-term consequences of each prescribing decision by linking their reimbursement to the achievement of goals such as reducing hospital readmissions and total medical costs as well as saving on prescription drug costs. They are holding physicians accountable for reaching generic prescribing rates, which may conflict with the drugs cardiologists believe are the most effective course of treatment for the ACS and AF to reduce the occurrence of myocardial infarction and stroke. Although ACO monitoring of patient adherence to AF and ACS drugs may increase sales, the ACO focus on cost-cutting drives many of these additional sales to generic competitors of brand name drugs in classes such as antithrombotics, antiarrhythmics, anticoagulants, and antiplatelet agents. Cardiologists and MCOs alike note that ACOs are already driving an increase in prescribing for generic mainstays, clopidogrel for ACS and warfarin for AF, and resulting in a decrease of prescribing for Plavix and Coumadin. This environment is becoming more challenging for branded drugs that seek to compete: such as Eli Lilly’s Effient (prasugrel), AstraZeneca’s Brilinta (ticagrelor), Sanofi’s Multaq (dronedarone), and Pfizer/Bristol-Myers Squibb’s Eliquis (apixaban). Branded drug marketers can use a variety of means to protect market share in the challenging ACO environment, including highlighting clinical advantages that keep patients out of the hospital or help patients be more compliant with their therapies. For instance, the novel anticoagulants, such as Pradaxa, Xarelto, and Eliquis, have demonstrated some clinical advantages over warfarin in preventing strokes and venous thromboembolic events. Drug marketers should be prepared to point out any brand advantages that meet the ACO’s goals of increasing compliance, reducing hospital readmissions, and other health outcomes improvements. In addition, many brands might need to preserve their place in ACO formularies by discounting prices under contracts favorable to ACOs.
Questions Answered in This Report:
- Establishment of ACOs: What do insurers hope to gain by developing ACOs for their commercial populations? How many beneficiaries and providers are participating today and in 12 months’ time? 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? What are MCOs’ enrollment, cost, and quality goals for their ACOs? What is the minimum size an ACO must be to establish its own formulary?
- ACOs’ impact on prescribing behavior: What performance and efficacy measurements are payers using to determine bonus payments to physicians and hospitals? How are these measurements likely to impact prescribing behavior in the treatment of ACS and AF? 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? What weight do MCOs assign to competing goals, such as reducing prescription drug costs versus reducing hospitalizations?
- Presence and role of distinct ACO formularies: Which formularies are ACOs following, now and in 12 months’ time? How are ACOs favoring specific drug classes and what specific brands among the AF and ACS treatments are being favored? Is prescription drug spending included in the ACO cost measurements? How is that measurement influencing prescribing behavior for specific branded and generic drugs for ACS and AF? What is the magnitude of this influence? How do payers expect ACOs to impact medical costs and prescription drug costs? What are payers measuring as part of ACOs?
This U.S. Physician & Payer Forum reveals physicians’ and payers’ insights into the changes in prescribing practices in the United States for ACS and AF drugs due to participation in ACOs. The report is based on a survey of 100 non-interventional cardiologists, 29 MCO pharmacy directors, and 13 MCO medical directors at MCOs that either currently contract with ACOs or expect to do so within 12 months. We highlight reimbursement arrangements, formulary restrictions, metrics tied to provider compensation, and other factors that influence decisions to use branded drugs or generic alternatives. The report explores opportunities for drug developers to advocate for their brands consistent with ACO goals and to protect or expand their market share. Specific therapies examined within the ACO context include Eli Lilly’s Effient (prasugrel), AstraZeneca’s Brilinta (ticagrelor), Sanofi’s Multaq (dronedarone), and Pfizer/Bristol-Myers Squibb’s Eliquis (apixaban).
Markets covered: United States.
Primary research: Online survey of 100 non-interventional cardiologists, 29 MCO pharmacy directors, and 13 MCO medical directors.
Population segments: Our analysis involves patients covered under Medicare, Medicaid, and commercial health plans.