Patients may change payers and providers over time. This can be due to changes in life circumstances—geographic relocation, getting married, a new job, etc.—or due to changes in health insurance coverage or provider preferences. Lower-income individuals in particular may move across payers as they shift between Medicaid, exchanges, and business coverage based on employment and income levels.
Patient mobility raises several issues for CGT. First, it complicates follow-on patient monitoring and outcomes evaluation over time, which will be important as we seek to better understand the performance of these new, innovative therapies. Second, for multi-year Precision Financing Solutions, patients moving across plans may be a risk in today’s market for the first payer, who bears the CGT expenditures, while the next payers reap the lower future expenses potentially associated with cost offsets. Thus, the first payer may have an incentive to avoid treating the patient with CGT, even if from a system level it would be the optimal choice. Patient mobility also inhibits the patient tracking that the first payer needs to adjudicate a performance-based outcome, as transferring the first payer’s contractual terms to subsequent payers is unlikely.
In creating access solutions for a new durable therapy, stakeholders should develop a clear approach for monitoring patients over time. Any contractual agreement for a multi-year Precision Financing Solution will also need to explicitly address potential patient mobility and adjudication of patients lost to follow-up.
Additional discussion of issues associated with patient mobility may be found in the FoCUS research brief Impact of Patient Mobility on Annuity/Performance-based Contracting.