Outcome-Based Pricing for New Pharmaceuticals via Rebates: A Firm-to-Payer Transfer Makes Outcome-Based Pricing Better for Both Firm and Payer if and only if the Drug Is High-RiskResearch Paper
Motivation
New brand-name drugs, in particular biologics, are expensive. Their benefit is also uncertain: a given patient cannot know in advance whether the treatment will work for her. Outcome-based pricing (also called performance-based or risk-sharing agreements) responds to this. The manufacturer is paid only when the treatment reaches a pre-specified goal and rebates the price otherwise. Agreements of this kind between manufacturers and payers have been signed for cholesterol, diabetes and oncology drugs. Carlson et al. (2010) give a taxonomy. Whether such a contract actually helps the parties that must agree to it is a question about incentives. It cannot be settled by noting that the patient bears less risk.
E. Adida (Management Science, 2021; accepted manuscript at eScholarship) studies it in a three-stage game between a monopolist firm, a payer and risk-sensitive patients. The patients follow prospect theory (Kahneman and Tversky 1979; Tversky and Kahneman 1992). The paper's headline result is that, in the region where the payer covers the drug under both systems, the firm and the payer typically disagree about outcome-based pricing. A side payment from the firm to the payer can make both strictly better off, but only for high-risk drugs. This mission formalizes that result and the chain of equilibrium computations that leads to it.
Setting
There are patients with values , , a unit cost , a co-insurance rate and a success probability . On success the payer gains a fixed surplus . The game has three stages.
- The firm announces a price .
- The payer decides whether to cover the drug. With coverage a buyer pays the share of the price and the payer pays ; without coverage .
- Each patient observes her value and buys iff her expected prospect-theory welfare is non-negative. Her value function is for and for , with and .
Under uniform pricing the price is paid on every purchase, and the buyer's welfare is . Under outcome-based pricing it is paid only on success, and the welfare is . Demand is times the measure of buyers in . The firm earns per buyer under uniform pricing and under outcome-based pricing. The payer's objective is its own expected payoff plus the patients' total expected (risk-neutral) payoff. It covers iff its objective with coverage is at least its objective without. An equilibrium price maximizes the firm's realized profit, with the payer's coverage response, over all .
Let
A drug is high-risk if and low-risk if ; the risk premium is positive exactly for high-risk drugs. Assumption 1 is . Assumption 2 is
with , , and the solution of . It is the region of large payer benefit, in which both systems end in coverage. Finally,
Formalization targets
Goal: Proposition 4
Under Assumptions 1 and 2, let and be equilibrium prices, and write and . Then
and, if and , : every transfer strictly between the two amounts, which runs from the firm to the payer, works.
Milestones
In attack order:
- the purchase rules (, resp. ) and the closed forms of demand and payer objective;
- Lemma 1 ( away from and ) and the shape of ;
- the coverage rules, Propositions 1 and 2;
- the equilibrium prices, Theorem 1 part 1 () and Theorem 2 part 1 (), and their combination under Assumption 2;
- the firm and payer comparisons, Proposition 3 parts 3 and 6, with the identities and ;
- the joint-surplus identity of the proof of Proposition 4 and the positivity of its bracket.
Significance
Proposition 4 says that for a high-risk drug outcome-based pricing raises total firm-plus-payer surplus, even where it hurts the payer. A negotiated side payment therefore always exists that makes both parties prefer it. For a low-risk drug no such payment exists, because the payer's gain is smaller than the firm's loss. The result locates where outcome-based contracts can be self-enforcing and identifies the risk premium as the quantity that decides it. In this model the patients' loss aversion and risk sensitivity act on the comparison only through and .
The paper proves the result with explicit algebra once the equilibrium is pinned down. The formalization adds two things. First, the equilibrium layer is checked, not assumed: the statements quantify over the backward-induction equilibrium prices, with an explicit payer coverage rule and an integral model of demand. The closed forms and the unique optima , become theorems. Second, the formalization makes the small hypotheses explicit (positivity of , non-negativity of , strict versus weak improvement), which the published proof uses without listing. As far as is known, none of these results has a machine-checked proof.
Difficulty
The algebra of Propositions 3 and 4 is short once and with coverage are established. The work is in establishing them. The firm's realized profit is a discontinuous function of the price, because the payer's coverage decision switches at the thresholds , , , , which depend on the regime of . Showing that is the unique global maximizer requires comparing the covered and uncovered profit curves on every piece. It uses Assumption 1, the bound (which places above and above ), and the monotonicity of through the root of . Reading the closed forms off the paper's formulas is not enough: they must be derived from the purchase rule, which itself rests on the prospect-theory inequality . A natural shortcut is to state Proposition 4 at and directly. That deletes the equilibrium content and is not the goal.
Formalization scope
All quantities are real numbers in one structure Params with a Standing predicate: , , , , , . Two of these are added to the page's assumptions: ( divides by ) and (used in the proof of Theorem 1).
Powers are Real.rpow on non-negative bases only. The roots (of ), (of ) and (of ) are passed as numbers together with their defining equation on ; uniqueness is a milestone. Demand and patient payoff are a Lebesgue measure and a set integral over the buyers in . Ties follow the paper: an indifferent patient buys, and an indifferent payer covers. "The firm prices at " is read as " is the unique equilibrium price". "Better for both parties" is read as strict improvement, and the paper's closed range of transfers is replaced by the open range, because at its endpoints one party is only indifferent. The payer's side of every comparison is its objective .
A formalization that fixes and by hypothesis, or takes the closed forms as definitions, would make the goal an algebraic identity. The goal here quantifies over all equilibrium prices of the integral model.
A complete development needs elementary real analysis (convexity and monotonicity of , rpow manipulations), Lebesgue measure and integrals over intervals, and piecewise maximization of concave quadratics. The prospect-theory value function and the threshold purchase rule are reusable for other behavioral pricing models. Proofs of any milestone are welcome, as are proofs of the omitted parts of Theorems 1 and 2 (the constrained prices , , , ).
Selected references
- E. Adida, Outcome-based pricing for new pharmaceuticals via rebates, Management Science 67(2), 2021. https://doi.org/10.1287/mnsc.2019.3574 (accepted manuscript: https://escholarship.org/uc/item/0702h9wp)
- D. Kahneman, A. Tversky, Prospect theory: An analysis of decision under risk, Econometrica 47(2), 1979. https://doi.org/10.2307/1914185
- A. Tversky, D. Kahneman, Advances in prospect theory: Cumulative representation of uncertainty, Journal of Risk and Uncertainty 5(4), 1992. https://doi.org/10.1007/BF00122574
- J.J. Carlson, S.D. Sullivan, L.P. Garrison, P.J. Neumann, D.L. Veenstra, Linking payment to health outcomes: A taxonomy and examination of performance-based reimbursement schemes between healthcare payers and manufacturers, Health Policy 96(3), 2010. https://doi.org/10.1016/j.healthpol.2010.02.005
- G.P. Cachon, M.A. Lariviere, Supply chain coordination with revenue-sharing contracts: Strengths and limitations, Management Science 51(1), 2005. https://doi.org/10.1287/mnsc.1040.0215