Friday, April 28, 2017

Building the Infrastructure for Outcomes-based Contracts

Today’s guest post comes from Scott Pribyl, CEO of mRx Ventures.

Scott discusses outcomes-based contracts for specialty drugs. He describes the challenges associated with data collection and collaboration among all the stakeholders—physicians, specialty pharmacies, pharmacy benefit managers (PBMs), third-party payers, Medication Therapy Management (MTM) companies, and patients.

To address these issues, Scott describes SamplifyRx, an outcomes infrastructure solution that allows all the stakeholders in the patient’s journey to track and manage patient outcomes and data. He argues that this technology can enable and manage outcomes-based contracts and reimbursement.

To learn more about the SamplifyRx outcomes infrastructure solution, email Scott Pribyl ( or connect with him at Asembia’s 2017 Specialty Pharmacy Summit next week in Las Vegas.

Read on for Scott’s insights.

Building the Infrastructure for Outcomes-based Contracts
By Scott Pribyl, CEO, mRx Ventures

Outcomes-based contracts are growing in popularity because they can align pricing with clinical efficacy. This evidence-based approach focuses on treating the patient to a pre-defined goal that measures the medication’s clinical benefit. However, the current workflow was not designed to automate both the adherence and outcomes data into the reimbursement process.

Without an infrastructure and ability to integrate directly into the reimbursement workflow, outcomes-based contracts will be difficult to scale and may be impossible to achieve.

Outcomes-based contracts need to map the entire patient journey, requiring tremendous amounts of patient clinical data that must be coordinated between all care team members, tracked over the course of the treatment, and used to prove that a medication worked as expected.
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Major Challenges in Implementing Outcomes-based Contracts

Specialty drugs are moving from fee-for-service to outcomes-based contracts. However, the logistics and infrastructure have not been established. There is a need to create and implement new standards so that all of the parties including the patient, payor, manufacturer and pharmacy can participate.

For specialty to implement outcomes-based contracts, the following solutions must be created:
  • Online library of outcome metrics to capture available to any user
  • Central data repository to aggregate outcome metrics captured
  • Outcomes specific API to capture and submit automatically
  • Patient dashboards to track patient progress for any user
  • Collaborative Network for seamless sharing of patient data
  • Patient-centric HIPAA-compliant workflow including patient permissions
  • Claims integration for tying outcomes to the claims reimbursement process

Coordinating Outcomes Data

Collaboration is mandatory for an outcomes-based contract to be successful. Each participant must be able to support their role in the outcomes-based contract process. A roadmap should be established so roles and responsibilities are clearly defined. The outcome metric defined in the contract must be easily accessible to all care team members for consistent data capture.

The SamplifyRx platform solves these problems for all members of the care team. It allows the PBM or health plan to define outcome metrics and questions that need to be tracked throughout the process. Using the agreed upon metrics, the outcomes can be standardized no matter how or where they are captured:
  • In-office visit
  • Telephone call (MTM or call center)
  • Direct messaging
  • Patient app
  • Medical device (like a glucometer)
  • Telemedicine
  • Any touch point within an Integrated Delivery Network (IDN)
Any party in the process can invite the other members of the care team to participate in the process including the specialty pharmacy, MTM company, PBM or prescriber.

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Outcomes and adherence data captured from any care team member can be consolidated into actionable reports. A centralized database allows for aggregation of every patient interaction and can be a proof source that can be accessed by analytic engines.

Integrating Outcomes into the Claims Workflow

Current rebate contracts can also be tied to adherence—which can be captured automatically through the claims data. However, outcomes are not typically captured in the claims data, presenting an opportunity to integrate outcomes-based contracts automatically into the reimbursement workflow. Since rebate contract administrators may handle over a million rebate claims every day, an automated solution is required to solve this problem at scale.

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Outcomes + Adherence Data File

Outcomes and adherence data can be combined into a single data file when automatically uploaded from any patient interaction. This combination of outcomes plus adherence data creates an opportunity to standardize the data file. This new data file (that we call RxClaimsOM) has the potential to provide daily patient treatment information in conjunction with when the drug was taken.

By quantifying the data at baseline and having a specific, contractual goal at the end of the contract, the rebate contract administrator can be notified if the patient does not meet the endpoint. The manufacturer rebate would then be issued to the PBM.

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Dan Schroeder, President of Gateway Health Partners, a rebate contract administrator, said:
“With the SamplifyRx platform we can easily integrate outcomes into our claims data and issue rebates, claw backs or money back guarantees for outcomes-based contracts as efficiently as our current rebate contracts."
Outcomes-based Contracts Keys to Success

Companies already have resources to manage specific parts of outcomes-based contracts, but there needs to be a framework to make collaboration easy. So we built the infrastructure for an outcomes superhighway so all roles and functions will have the same system to collaborate and share data.

The keys to successfully managing the outcomes-based contracts are:
  • Universal access to the same outcomes metrics to track
  • Collaborative sharing of outcomes via an API or microservices
  • Integration of outcomes and adherence data files into claims workflow
  • Ability to notify rebate claims administrator with proof of success or failure
  • Central repository of aggregated data for reports and analytics companies
SamplifyRx’s outcomes infrastructure solution is now available to manage any new or current outcomes-based contract as the outcomes proof source integrated into the reimbursement workflow.

If you have questions you can email Scott Pribyl (, or connect with him at Asembia’s 2017 Specialty Pharmacy Summit next week in Las Vegas.

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