What Payers & Manufacturers Look for in Outcomes–and the Why Behind It

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What Payers & Manufacturers Look for in Outcomes–and the Why Behind It

In a time where therapy costs and options are escalating rapidly, stakeholders need to know that they’re getting positive results. This can present a challenge for specialty pharmacies, as they work to create and stabilize the various systems and processes needed to effectively measure and communicate their outcomes in an industry that currently lacks universal data standards.

There are several steps for pharmacies to accomplish this. They need to build a team and operational infrastructure that systematizes positive outcomes, ensures that they have the right tools in place to measure and interpret data into meaningful outcomes reports, and deciphers which metrics and reports are most valuable to each stakeholder.

When it comes to providing stakeholders with the right information, it all boils down to value: both payers and manufacturers want to know that they’re reaping value from their costs and efforts, and financial, clinical, and operational data is key for measuring and quantifying these outcomes.

What Payers Look For

The ultimate question payers are asking is: Are we getting what we’re paying for?

What Payers & Manufacturers Look for in Outcomes – and the Why Behind It blog-02

This question can be answered by assessing items like:

  • Appropriate drug selection and dosing consistent with drug use policy
  • Validation of drug value based on quality and cost metrics
  • Analyzing outcomes at the medication and disease-state level
  • Comparative effectiveness analysis, which also helps to make more precise formulary decisions
  • Improved patient outcomes including patient satisfaction


In terms of the specific metrics that help to gain clarity on these items, payers will examine data related to finances, patient health and outcomes, and quality of service.

Specialty pharmacies should report financial outcomes data including:

  • Patient financial assistance results
  • Cost per prescription
  • Per member, per month costs
  • Total cost by category/class
  • Patient/care giver interventions to promote proper drug use, adherence, side effect management, etc.; plus hard and soft cost savings from such interventions
  • Prescriber interventions to assure correct drug selection and dosing; plus savings resulting from such interventions

Important clinical outcomes metrics include medication possession ratio (MPR), proportion of days covered (PDC), and adverse events. Payers will also examine disease-specific outcomes data, such as clinical sustained virologic response (SVR) in hepatitis C patients, exacerbations in multiple sclerosis patients, and forced expiratory volume in 1 second (FEV1) in cystic fibrosis patients.

To assess the performance of the facility as it relates to outcomes and cost-effectiveness, payers look at operational and service outcomes such as:

  • Call center statistics, including speed to answer and abandonment rate
  • Error rates
  • Time to fill
  • Turnaround time
  • Patient satisfaction

What Payers & Manufacturers Look for in Outcomes – and the Why Behind It blog-03What Manufacturers Look For

Manufacturers seek data that proves the efficacy and value of their medications. This can be accomplished through:

  • Measuring outcomes at the medication and disease-state level
  • Understanding financial, clinical, quality of life, and patient satisfaction measures
  • Identifying expanded or new indications to existing drug formulations

For manufacturers to draw meaningful conclusions from this data, it must show consistency in how drugs are prescribed, dispensed, and used based on established protocols. For this reason, patient onboarding data is an important addition to clinical outcomes data.

Specialty pharmacies should provide patient onboarding data that includes:

  • Referral volume for the manufacturer’s drug
  • Stages of approval: when the prescription is received, and benefits investigation including prior authorization and any denials, appeals, and overturns
  • Time between each stage
  • Overall time from receipt to when the drug is dispensed
  • Success rate: percentage dispensed by the pharmacy, and percentage referred out and to whom

Manufacturers also seek patient clinical data, such as:

  • Adherence and persistency information
  • Medication possession ratio (MPR)
  • Proportion of days covered (PDC)
  • Quality of life measures
  • Disease progression scores

Specialty pharmacies should include information on how they work to optimize outcomes, such as pharmacovigilance strategies and risk evaluation and mitigation strategies (REMS). Inventory levels and payer data are also useful, including Medicaid, insurance, copay assistance, and copay to members.

Higher Expectations, More Pressure

Payers and manufacturers continue to place higher expectations on higher-cost therapies. Keith Cook, VP of MedImpact Specialty Pharmacy, estimates that payers are expecting adherence rates as high as 90 percent for cancer drugs and 95 percent for hepatitis C drugs. They’re benchmarking these outcomes data against the disease state as a whole, and comparing results to other drugs.

To standardize and simplify this process for all stakeholders, the National Association of Specialty Pharmacy (NASP) is working to develop core metrics for use by all stakeholders and organizations. 

In the meantime, specialty pharmacies are investing in specialized solutions like therapy management platforms and data analytics systems to ensure that they’re providing exceptional service, generating consistently positive outcomes, and satisfying stakeholders’ performance and reporting requirements.


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