Furthermore, the authors found that only 1.4 percent of physician variation within organizations could be explained by observable physician characteristics (e.g. However, a new study using Medicare enrollment and claims data from 2008 to 2013 finds that primary care physicians at the 90th percentile of LVHC provision for their provider organization provide 60 percent more LVHC services than physicians at the 10th percentile at the same provider organization. Prior studies of LVHC service provision have thus far been unable to measure the variation in LVHC provision at the physician-level. One important driver of elevated healthcare spending in the United States is the over-provision of low-value health care (LVHC) services. Provision of Low-Value Health Care Services Common for All Physicians, but Varies Widely Within Regions and Organizations The authors acknowledge a number of obstacles would need to be worked out before such a model could be implemented, including establishing long-term agreements between payers, manufactures, and PBMs and the effect such an agreement may have on future product competition. Using PCSK9 inhibitors as an example, the authors modeled scenarios where the drug had low, expected and high efficacy and showed that in all three scenarios, manufactures, patients, and payers are all better off compared to the status quo where launch prices are set high and remain there until patent expiry. The price would prevail during a fixed reward phase before being reduced to facilitate access uptake during an access phase. The authors propose a low initial price during an evaluation phase, followed by a higher or lower price that depends upon the drug’s real-world performance. A new NEJM catalyst article outlines a different approach: a tiered pricing system that allows prices to vary over fixed time intervals as data on the drug’s real world efficacy is gathered. First and foremost, though new drug prices are based on clinical trial outcomes, manufacturers and payers often disagree about the value of the drug over the long run in a real world setting.
While the goal of value-based pricing models is to better align incentives between payers and providers, implementing such models within the pharmaceutical space has proven challenging. Goldman, Karen Van Nuys, Wei-Han Cheng, Jakub Hlavka, et al
Senior Fellow - USC Schaeffer Center for Health Policy and Economics Proposed Three-Part Pricing Model for Drugs with Uncertain Efficacy Allows Prices to Change with New Information Nonresident Senior Fellow - Economic Studies, USC-Brookings Schaeffer Initiative for Health Policy
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