Cigna was one of the first big insurers to sign on to Novartis’ pay-for-performance plans for its heart failure drug Entresto. Now, the top healthcare payer has struck similar deals on the expensive new cholesterol-fighting meds from Amgen, Sanofi and Regeneron.
Cigna will get bigger discounts on Praluent, from Sanofi and Regeneron, and Repatha, from Amgen, if the PCSK9 inhibitors don’t deliver the goods for patients. The insurer announced the value-based reimbursement deals Wednesday.
Pay-for-performance arrangements aren’t commonplace, but they’re growing more so as pharma rolls out pricey, next-gen drugs and payers look for ways to control their spending on them. About 14% of U.S. payers have at least one pay-for-performance pricing arrangement, up from 10% in 2014, according to a new specialty reimbursement report from EMD Serono. Another 30% of plans say they’ll have an outcomes-based deal in place within 12 months.
The list prices on both PCSK9 drugs top $14,000, and though they’ve cut “bad” LDL cholesterol significantly in clinical trials, there’s no proof yet that the meds reduce the risk of heart attacks, strokes and other cardiovascular problems. With that outcomes data due later this year and next, payers have been diligent about restricting the drugs’ use to patients who tick every box on their prior authorization forms.
Cigna’s deal is a way to open up access to patients while limiting its costs. Cigna will track patients who use Repatha or Praluent to see whether they rack up similar reductions in LDL cholesterol as patients in clinical trials did. If so, then the drugmakers stick to their pre-negotiated discount with Cigna. If not, then the discounts increase. Though Repatha and Praluent haven’t proven to reduce heart risks themselves, lowering LDL is a generally accepted goal for preventing CV problems.
If the drugs work as expected, then the insurer can theoretically anticipate saving money on CV complications down the road, giving Cigna a payoff on its drug investments. If not, then it collects a bigger discount as a consolation prize. And in the process, it will collect data on medical and pharmacy claims to study whether its PCSK9 patients are reaping CV benefits.
Cigna isn’t the first to strike an outcomes-based deal on a PCSK9 drug; Amgen inked an exclusive arrangement with Harvard Pilgrim last year. And the PCSK9 meds aren’t Cigna’s first subjects in the pay-for-performance vein; it has value-based deals on meds for diabetes, multiple sclerosis and hepatitis C as well, the company said in a statement.
Cigna was among the first to strike a deal with Novartis on the heart failure drug Entresto, linking Cigna’s cost for the drug with its outcomes, including its ability to keep patients out of the hospital as shown in a clinical trial. Cigna rival Aetna also struck a pay-for-performance deal on Entresto that linked rebates to the drug's results. At the time, Novartis pharma chief David Epstein said the contracts set a "fairly modest" base rebate which will rise or fall depending on the drug's performance. If Entresto helps the plan save money on hospitalization or other costs, the rebate goes down. If it doesn't, the rebate goes up.
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