How Pharmas, Payers, and Providers Can Meet the ‘Triple Aim’

In recent years, with the Affordable Care Act and consensus on the “triple aim” (better outcomes and patient experience at lower cost), payers and providers have been moving toward a value-based healthcare system. But the pace has been slow, and other than a few paradigm shifts, which have been positive (accountable care ogrganizations, medical homes, growing use of telehealth, and self-insurers), there has not been significant changes in care delivery. 

Payers set pace

While some see the provider community as the primary player in meeting the triple aim, I believe the payer will lead the way, because it is the group that holds the purse strings. While providers want to meet the aim, fee-for-service financial incentives don’t support their efforts. Ultimately, financial incentives will motivate providers to change practice patterns, and financial incentives are driven by decisions of payers (both public and private). 

Payers are strongly indicating that value-based reimbursements are the future of healthcare, with the new Medicare financial incentives via the Medicare Access and CHIP Reauthorization Act (MACRA) legislation and a growing use of risk-based and capitated contracts in the private sector. Payers are also behind the increase in use of telehealth as a means of lowering costs and improving patient convenience.

So where does the pharmaceutical and clinical research community fit in this new paradigm? 

As value-based payments for pharmaceuticals become more common, pharma companies will be engaging more directly with payers and providers. They will need to gather data to prove value and will need to engage with patients to improve adherence to treatments (and by extension, outcomes).

But beyond this financial necessity of greater involvement, there is an opportunity to accelerate value-based care through a stronger partnership between payer, provider, and pharmas. All three, along with patients, can benefit from this partnership, with pharmas offering two important opportunities to payers and providers, both involving data exchange.

For providers, pharmas offer the opportunity to gain value, in the form of insights to guide treatment decisions, from the enormous volume of electronic patient data they house. This data, of course, has to be appropriately anonymized to protect patient privacy, and pharmas will need to be specific about how and why the data will be used. R&D uses should be clearly separated from marketing and sales uses, and patient consent must be gained for using anything other than anonymous data.

Pharmas need the anonymous data to speed up drug research and development through better understanding of target patient populations, their most desired target outcomes, likely responders, non-responders or adverse responders, to a new drug or for repurposing existing approved therapies. Access, linkage, and analytics of this data in an integrated research platform can enable pharmas to test hypotheses before risking time and money in clinical trials. The data could also help predict which kinds of patients are good candidates for trials, and which are not, based on their clinical markers and patterns of adherence to treatment. Pharmas and contract research organizations (CROs) have the budget to support this spend on patient selection/recruitment, as it would significantly reduce their overall costs.  

In addition to helping discover new treatments and lower the cost of research, providers and payers could benefit from the insights learned to help better match patients with existing treatments.  

On the other side of the drug delivery process, lies an opportunity for payers to contract for reduced-cost pharmaceuticals in exchange for referrals from payers to their in-network provider communities, provided that the drug offers positive outcomes comparable to the results from published trials. To show evidence of efficacy takes real-world data, and pharmas need to collect information on responders, semi-responders, and non-responders to the medication. 

All of this information will be needed to retain or renegotiate contracts with the payer community, and will require significant exchange of information between providers and payers and pharmas. Pharmas will need to link clinical, claims, and pharmacy information to identify responders from non-responders, positive from negative outcomes, adverse reactions, and correlation of outcomes to medication adherence patterns.

Integration imperative

It is in this exchange that we should add a fourth partner to the community, and that partner will be a systems integrator. Payers have claims data, providers have electronic health record (EHR) systems, and pharmas have enterprise resource planning (ERP) and laboratory systems. Adding to the complexity, software designers tailor their products to narrow-use cases within a specific market, resulting in a vast array of disparate applications. Payers can have two systems for care management and customer service, with a third for mobile interactions. Providers can have outreach systems different from the EHR and also multiple, yet related, portals. And in the pharma community, the number of application systems is staggering and growing. 

None of these systems are designed to interact easily with each other or share data with outside platforms, including those that are cloud-based and platform as a service (PaaS). To combine data from these systems

requires massive systems integration. The interim step has been the sometimes-elusive, all-encompassing data lake to hold everything from every system, from structured to unstructured data, from which data can be drawn for all purposes. While this approach has benefits, positive use cases inside of a division or function, and should sit at the core of a corporation, sharing the information across the payer, provider, and pharma partnership brings numerous challenges in data and system integration, causing the continued use of calls, faxes, and flat files.  

 A supportive application to each organization’s core data layer is a platform that can accept, organize, and analyze data from multiple sources and platforms, and within the patient-centric perspective, that would be the customer relationship management system (CRM). It’s a platform that has been adopted by all three communities (mostly salesforce.com). Payers are starting to twist it toward care management, as it offers a way to organize, analyze, and use non-clinical data that is critical in population health management. A West Coast hospital system, for instance, has over 70 apps on the salesforce.com platform that sits on top of its EHR to ease the entry and view of information for individual roles, from the nurses to the staff to the patients themselves. Pharma has gone all in, with the top 200 globally adopting Veeva for sales and marketing activity (Veeva is built on the salesforce.com platform).

Data dreaming

Imagine the scenario of a pharma and CRO looking to accelerate enrollment in a trial and paying for provider clinical data to organize and analyze its search (providers earning new revenue streams) and during the trials identify those that actively adhere and those that don’t. This data could be used to create a persona that can be shared with payers once they begin to correlate actual users of the drug and outcomes. Once a treatment is approved and prescribed, the provider can follow up with patients via salesforce.com apps and telehealth capabilities and allow pharmas and payers to use the community feature to mine the feedback, understand the experiences, and even get in front of any adverse effects or complaints.

Imagine if a patient has a complaint and shares it online, not in Twitter or Facebook, as most people do now, but

in a secure, collaborative community forum. Users of the platform would be other people with the same condition and using the same drug, as well as stakeholders from the provider, health plan, and life science communities.

Instead of venting frustration, as many patients do now, a collaborative platform offers the opportunity for the healthcare insurer’s care manager to inquire as to how the patient is feeling and suggest follow-up with the doctor. Or the care manager could facilitate a conversation with the pharmaceutical manufacturer to understand if the patient is experiencing a known or new side effect. The care manager also could provide valuable interaction information based on other drugs the patient might be taking and provide a significantly higher level of information about the drug than the primary care physician. 

Beyond the glitz

I don’t know about you, but I’d like to live in a world where my health plan texts me, my prescription drug company (whose company name I probably don’t even know) offers me a discount or to pay for a follow-up visit, and my doctor has more information about what is happening with users of the therapy and the real-world efficacy of its outcomes.

But the answer is not in simply procuring a platform; it’s all in the integration and the awareness of the real-world business of quality care across the payer, provider, and pharmaceutical ecosystem. And that is where the fourth partner, the systems integrator, brings tremendous value. 

Adam Nelson is Chief Operating Officer, Life Sciences, at NTT DATA Services. He can be reached at Adam.Nelson@nttdata.com