The American journal of managed care
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Health systems and provider groups currently lack a systematic mechanism to evaluate the financial implications of value-based alternative payments. We sought to develop a method to prospectively quantify the financial implications, including risk and uncertainty of (1) transitioning from a fee-for-service to an episode-based payment model and (2) modifying episode-specific clinical cost drivers. Finally, we highlight practical applications for the model to help facilitate stakeholder engagement in the transition to value-based payment models. ⋯ The simulation demonstrates that both financial parameters and clinical cost drivers significantly affect the expected financial outcomes for stakeholders in value-based payment models.
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Using a US payer perspective, this study aimed to compare the lifetime cost-effectiveness of adding sodium-glucose cotransporter 2 (SGLT2) inhibitors vs switching to glucagon-like peptide 1 receptor agonists (GLP-1 RAs) among patients with type 2 diabetes who were not at glycated hemoglobin A1c target after dual therapy with metformin and dipeptidyl peptidase-4 (DPP-4) inhibitors. ⋯ Intensification with an SGLT2 inhibitor on top of a DPP-4 inhibitor demonstrated slightly better efficacy and cost savings compared with switching to a GLP-1 RA in patients not at glycemic goal with metformin and a DPP-4 inhibitor.
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In response to brand-name drug manufacturers developing co-pay assistance programs to help patients pay high out-of-pocket costs for expensive brand-name drugs, insurers have developed co-pay accumulator adjustment programs (CAAPs) that exclude payments made by drug manufacturer assistance programs when calculating whether beneficiaries have met their yearly out-of-pocket maximums. By doing so, these programs are intended to drive beneficiaries to lower-priced generic alternatives. A rule finalized in July 2020 makes such programs permissible even when a brand-name drug does not have a generic or medically appropriate alternative, while not requiring transparency from payers about the existence of such programs. This commentary explains how CAAPs work and how this finalized rule may affect spending on prescription drugs.