Dr Jennifer Graff: How the US Healthcare System Can Encourage High-Value Care

Europe has found ways to make value-based care work, but the US market is very different, which means there are different factors in the United States that can work to encourage high-value care, according to Jennifer Graff, PharmD, vice president of comparative effectiveness research at the National Pharmaceutical Council.

Transcript (slightly modified)

What can we learn from models of approval and reimbursement decision making of specialty drugs in other countries, particularly throughout Europe?

The United States is quite a different market than Europe; we see this in a really fragmented market. Let me give you an example; in Europe, if you pay for a treatment that may cure a disease or slow the progression, the patient stays within that single-payer health system. So, the payer that paid for that medication at one point in time, will also receive the benefits of that treatment, either in lower healthcare costs, or better healthcare for that patient several years down the road. In the US that patient has likely moved on to a second or third health plan, so they aren’t reaping those benefits. So, while we can learn many things from Europe, the United States is a complex system.

What can we do in the United States? I think there are 3 things. First, for patients, we need to make sure we are incentivizing patients to get the treatments that work best for them. There are things that we can do to make sure that patients—who just by bad luck, bad genes, or have tried and failed other treatment alternatives and now need more costly therapies—that they aren’t hit with a double whammy of higher copay or coinsurance, as well as poor health. We can do things to try to ensure that patients are paying for treatments and not penalized financially for their genes or bad luck.

The second is encouraging providers. We have a very sick fragmented healthcare system; so if you incentivize a provider in one way to encourage high value care then the hospital or the payer may have different incentives, so it gets very complex. We need to align these incentives from the provider, to the health system, to the payer to encourage high value care rather than low value care and therefore free up dollars.

The third element that we need to consider is, how does our payment landscape work? We have legal, regulatory, and information technology (IT) barriers that are really challenging the opportunities to develop new and innovative payment landscapes. So, we can hopefully address these by multi-stakeholder collaboratives, public-private partnerships, and others to try to ensure that those legal issues such as anti-kickback statute of limitations, regulatory issues such as Medicaid Best Price, or even IT issues to provide payment for the indication that the patient is receiving the treatment for—that those are all resolved so we can incentivize high care value and treatments.