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Outcomes-Based Rebates in Pharmaceuticals: Essential Insights for Employee Benefit Brokers

Warrants in outcomes rebates are a financial mechanism used by pharmaceutical manufacturers in their contracts with payers, such as PBMs, insurance companies or government healthcare programs. These warrants are essentially a form of guarantee or insurance that the pharmaceutical companies provide regarding the performance or effectiveness of their drugs. Here’s how outcomes-based rebates in pharmaceuticals work and why they are used:

  1. What are Warrants in Outcomes Rebates?
    • Warrants in outcomes rebates are contractual agreements between a pharmaceutical manufacturer and a payer (i.e. PBM, health plan). In these agreements, the manufacturer promises a rebate or financial return if the drug does not meet specified outcomes or performance metrics.
    • These outcomes or metrics are typically related to the drug’s effectiveness in treating a condition, the improvement in patient health, or achieving certain health benchmarks.
  1. How Do They Work?
    • When a pharmaceutical company sells a drug, it can include a warrant in the contract that promises a rebate if the drug does not achieve the agreed-upon outcomes.
    • The specific outcomes are predefined and could be based on clinical trial data, real-world evidence, or agreed-upon health metrics.
    • If the drug fails to meet these benchmarks, the pharmaceutical company provides a rebate to the payer. This rebate could be a partial or full refund of the drug’s cost.
  1. Why Do Pharmaceutical Manufacturers Rely on Them?
    • Risk Sharing: Warrants in outcomes rebates allow pharmaceutical companies to share the risk of drug performance with payers. This can be particularly important for expensive drugs or those with variable outcomes.
    • Market Access: By offering these warrants, manufacturers can make their products more attractive to payers, potentially increasing market access and acceptance.
    • Building Trust: These agreements can build trust with payers and prescribers by showing confidence in the drug’s effectiveness.
    • Support for Premium Pricing: For drugs that are highly effective but expensive, warrants can justify the high cost by tying the price to actual performance.
    • Encouraging Innovation: They can encourage innovation by aligning the financial incentives of the manufacturer with the actual health outcomes of patients.

To manage the risk associated with outcomes-based rebates in pharmaceuticals, pharmaceutical companies may purchase insurance policies. These policies can cover the potential financial losses that arise if the drug fails to meet the agreed-upon outcomes and a rebate is due. The insurance essentially transfers a portion of the financial risk from the pharmaceutical company to the insurance provider.

Overall, warrants in outcomes rebates represent a move towards value-based pricing in the pharmaceutical industry, where the focus is on paying for the actual value or benefit provided by a drug, rather than just the drug itself. This approach can lead to more sustainable healthcare spending and better alignment of incentives among manufacturers, payers, and patients.

Tyrone Squires, MBA, CPBS

I am the proud founder and managing director of TransparentRx, a fiduciary-model PBM based in Las Vegas, Nevada. We help health plan sponsors reduce pharmacy spend, by as much as 50%, without cutting benefits or shifting costs to employees.

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