Use of adherence monitoring in drug contracts tied to outcomes:put patients first

Healthcare payers, including NHS England, are making increasing use of outcomes based contracts for new drugs. Under these contracts payment for drugs is tied to real world effectiveness instead of a fixed price per unit. A typical agreement might entail a manufacturer either wholly or partially refunding drug costs if the agreed outcome threshold (cure, reduction in mortality, biochemical outcome) is not met. Although these contracts can facilitate access to new drugs when cost effectiveness is unclear, they present challenges with measuring outcomes and have potential for political and commercial conflict of interests. Patients’ adherence to drugs attains new importance in outcomes based contracts. Manufacturers may argue that suboptimal adherence is responsible for a poor outcome rather than ineffectiveness whereas payers may argue the opposite. Medication non-adherence is widespread with rates of up to 50% reported in hypertension, diabetes, asthma and cancer, and the reasons for it are complex and poorly understood. One way to help assess whether outcomes reflect effectiveness is to include a requirement for adherence monitoring in outcomes based contracts. This has clear measurement advantages for both manufacturer and payer, but whether it is in the interests of patients is unclear. We consider how outcomes based contracts and adherence monitoring might affect patients within a nationalised health system such as the NHS.