LAUSR

Overview Pay-for-performance programs, which seek to better align incentives between insurers and clinicians, are increasingly being used to improve quality without necessarily increasing spending. For example, under Medicare’s hospital value-based payment program, reimbursements are based partly on hospital performance on measures of quality, satisfaction, and mortality rates. We have not seen similar progress in reforming reimbursements for prescription drugs. Recent approvals of expensive medications targeting common cardiovascular diseases—including proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, a new class of monoclonal antibody lipid-lowering therapy— provide an opportunity to use innovative reimbursement approaches to foster better accountability for patient outcomes. The use of PCSK9 inhibitors has been limited by access barriers, including high prices set by pharmaceutical companies and payer utilization management strategies. This gridlock disadvantages patients and their physicians. Outcomes-based pricing represents a promising strategy for improving access to PCSK9 inhibitors at a price commensurate with their value to patients and the health care system. In this Viewpoint, we describe outcomes-based pricing and why PCSK9 inhibitors are good candidates for it, evaluate how recently published data on the clinical efficacy of evolocumab (Amgen) affects using outcomes-based pricing agreements for PCSK9 inhibitors; and describe how insurers are integrating this new clinical data into outcomes-based pricing agreements for evolocumab.