Approaches to Value-Based Contracting with Clinical Strategies

Established in 2017, the UPMC Center for Value-Based Pharmacy Initiatives (VBPI),housed within the UPMC Center for High-Value Health Care, a non-profit research entity within the UPMC Insurance Services Division, has developed in collaboration with UPMC Health Plan Pharmacy, striving to promote greater value in medication use both within and outside of UPMC.

A new presentation by UPMC’s Chester Good, MD, MPH, and Jessica Daw, PharmD, MBA, given at AMCP Nexus 2019, explored the various models for value-based contracts, modified Delphi surveys, epidemiological analyses, and clinical initiatives. Using multiple sclerosis (MS) to portray value-based care (VBC), the presenters explained that prior MS VBCs were based on surrogate clinical indicators like MS-related ED visits, hospitalizations, adherence, relapse rates. They noted that the VBPI Delphi Survey, however, unanimously ranked worsening physical disabilityas the most meaningful MS outcome. This led to the creation of a novel approach to VBC based on patient-reported disability progression. This VBC is supported by the MS Clinical Wrap Around Program.

The contracting process with VBCs is longer than typical contracting and is much more granular. Risks are still very low and driven by the concerns of pharmaceutical brand teams. They are therefore often considered tilted towards the pharma side. The presenters identified two-sided risk as a method to advance conversation. Regarding data availability, they noted that Delphi results are not available in the dataset, that proxy data on limited population is generalizable across the entire population, and that there is a wide variation around data availability across plans.

The UPMC presenters went on to list diabetes, cardiac, opioid/MAT, and MS as therapeutic areas of focus for clinical programs. They noted that over 57% of the 1,200 referred diabetes cases involved intervention communicating to the provider office directly to remedy therapeutic complications.

The following statistics are presented regarding the diabetes clinical program:

  • Eight potentially avoided ED visit or Inpatient hospital stay.
  • 180 avoided unnecessary office visit or unnecessary medication.
  • 598 coordinated care, lowered medication costs, or provided education to member.

The change in the total cost of care for members participating in the MS clinical program was evaluated by comparing data taken six months before program initiation to that taken six months after. The MS program was found to be associated with a significant decrease in medical costs and a significant increase in pharmacy costs driven by increased utilization.



Good, C, Daw, J, et al. Innovative Value-Based Contracting Approaches with Comprehensive Clinical Strategies. Presented at: AMCP Nexus 2019; October 29 – Nov 1; National Harbor, MD.