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There has been recent policy interest in improving the affordability and access of prescription medications, including efforts to reduce disparities in access for low-income and minority beneficiaries. For example, the Inflation Reduction Act (IRA) is being implemented in response to continued concerns about drugs affordability, with a focus on reducing the price of selected drugs paid for by the Medicare program. States have also implemented a range of policies for reducing the unit price of drugs, such as preferred drug lists and multistate purchasing collaboratives. Legislation is currently being considered by congressional committees focused on pharmacy benefit managers (PBMs) in terms of rebates, certain types of transparency, spread pricing, and fee models.
These drug policies are unlikely to achieve their maximum impact if they are not integrated with care delivery policies. Even with a very low price, a drug may not be widely accessible without clinicians identifying patients with the relevant condition and comorbidities, prescribing the appropriate therapy, and managing its ongoing use. For example, getting statin therapies to those who benefit requires clinicians to screen for high cholesterol and cardiovascular disease risk, to partner with patients on ongoing use (such as if a patient is concerned about potential side effects), and to identify wraparound services or complementary therapies to further lower heart disease risk. Furthermore, clinicians play a vital role in determining the appropriate use of a given therapy and ensuring that a therapy is equitably provided to all those who need it.
Value-based payment (VBP) models focused on care delivery, such as accountable care organizations (ACOs) and specialty care models, provide an avenue for aligning quality measures, gain/risk sharing, and data feedbacks that impact prescribers with broader drug policy reforms to increase the benefit to patients. VBP models have different opportunities depending on whether the drugs are administered by clinicians or dispensed by pharmacies. Here, we provide an overview of challenges and opportunities for integrating clinician-administered and pharmacy-dispensed drugs into VBP models, highlighting short-term steps that commercial and public payers can take to align health care for both types of drugs.