Key ingredients for a successful VBA relationship: Clinical knowledge, analytic capability, and RWD expertise

April 2026 | Written by Jane Sullivan, MPH, and Ralph Quimbo, MA

Recent real-world insights generated from a value-based agreement (VBA) demonstrated a 4.9% decrease in annual mean inflammatory bowel disease (IBD)-related medical costs for treated patients over a 4-year period. This VBA emerged from a multi-step collaborative effort among CarelonRx, the pharmacy benefit manager (PBM) for Elevance Health; Carelon Research, Elevance Health’s research subsidiary; and Takeda that started in 2017, as described in this article1.

However, in the industry, this VBA is among the minority that reach the implementation stage, with only 33% of initiated VBA frameworks resulting in signed contracts for pharmaceutical manufacturers with payers2. This highlights the challenges faced as the industry shifts toward payment and delivery models that focus on value rather than volume as well as greater transparency of costs for payers, pharmaceutical companies, and patients.

The evolving reimbursement environment

The reimbursement environment has been dominated by traditional rebate models, but they have been criticized for often failing to align with the actual value of a therapy in terms of patient outcomes. As a result, some companies are phasing rebates out and exploring more effective methods to align drug costs with patient benefits, especially as legislation for PBM reforms continues to emphasize greater transparency and better patient access to therapies that improve outcomes within reimbursement models.

VBAs can be an effective alternative. They aim to proactively mitigate rising drug costs while ensuring treatments provide measurable value to patients. However, implementing them tends to be more complex than traditional rebates, slowing their adoption. This complexity arises from the fundamental purpose of VBAs: connecting a therapy's price to its performance in everyday clinical settings, as assessed using predefined outcomes based on existing real-world data (RWD).

Crafting a VBA can also be complicated by the shared financial risk between the pharmaceutical company and payer. In a typical VBA, the payer covers the upfront costs of a high-cost treatment, even if its real-world effectiveness is not yet confirmed. If the therapy does not meet the agreed-upon outcomes, manufacturers may provide rebates or reimburse the payer for part or all of the drug's cost as well as other drug-associated costs.

Common barriers to VBAs

Reaching consensus on strategic priorities is therefore a common challenge for VBA implementation. Misalignment between life sciences companies and payers can manifest in several areas:

  • Establishing clear, credible, and meaningful outcome measures that accurately reflect the therapy’s value and can be feasibly measured using the available data

  • Agreeing on what constitutes “value” for a specified endpoint and timeframe

  • Determining which analytic methodologies should be used within the VBA framework

  • Clarifying responsibility for the workload and costs associated with sourcing, administering, collecting, programming, analyzing, interpreting, and reporting RWD

Other barriers often involve having access to the required data, resources, specialized skill sets, and expertise required for real-world evidence (RWE)-related activities, which are critical to planning, executing, monitoring, and evolving VBAs. Additionally, market dynamics can influence a company’s perceived benefit of investing in the collaborative efforts required for successful VBA implementation. Although external pressures can motivate pharmaceutical companies to begin VBA discussions, the companies might lack the competitive incentive to commit fully to the necessary relationships and resource allocation.

Establishing an effective VBA

Given the inherent risks and challenges in establishing VBAs, building trust among the stakeholders is crucial for creating a successful framework. A trust-centered VBA contracting relationship between the payer and pharmaceutical company contributes to productive discussions and facilitates decision-making.

The following can help build that relationship and drive meaningful outcomes for all stakeholders:

  1. Start small and build a robust foundation
    This approach helps lower the barrier to entry and helps establish trust between stakeholders. It also provides a foundation from which to scale to more complex outcomes over time that reflect all stakeholders’ priorities.

    In the collaboration among CarelonRx, Carelon Research, and Takeda, the first phase involved an agreement around treatment continuation, as described in detail in this article1,3. This outcome measure was appropriate, clearly and completely defined, and readily operationalized using existing payer data sources. Once that precedent was set, later phases involved developing a predictive model to create a more comprehensive measure of drug performance, followed by fine-tuning the agreement for calculation of total IBD-related medical costs.

  2. Engage in a proactive collaboration committed to an outcomes-aligned approach
    More VBAs are completed when barriers are addressed collaboratively by payers and pharmaceutical companies4. Therefore, defining roles and responsibilities helps ensure accountability and transparency, enabling each stakeholder to understand their contributions. Creating a realistic timeline that allows time for early explorative discussions, alignment on outcomes and measurements, and building a roadmap for future growth also provides clarity on expectations and a more structured approach to addressing issues as they arise.

  3. View the process as continuous and iterative
    The perceived value of therapeutic outcomes often changes with market dynamics and evolving patient and physician expectations. To adapt, stakeholders need to commit to regularly collecting and analyzing new or refreshed RWD throughout the adjudication process to inform adjustments to the agreement, ensuring it remains relevant and an accurate measure of value.

Key considerations for VBA relationships

VBAs can involve multiple layers of coordination and expertise, including familiarity with clinical care pathways, insight into how claims and reimbursement decisions are evaluated, and experience with the types and analysis of RWD. When these competencies are unevenly distributed across various organizations, achieving alignment can be particularly challenging.

To streamline the establishment of successful VBAs, consider contracting with an organization that has a proven track record in this area, including collaboratively defining and measuring meaningful outcomes. Expertise and experience with RWD-based health economics and outcomes research (HEOR) methodologies, such as RWE generation, cost-effectiveness analysis, and patient-reported outcomes are also key. Additionally, strong relationships with health plans and PBMs can facilitate the operationalization and evolution of these agreements.

Fostering more effective, collaborative relationships enables the successful implementation of VBAs, ultimately benefiting patients and healthcare systems alike.

References

  1. Thomas N, Sefain H, Stanek E, Visaria J, Cziraky M, Moran K, et al. Real-world insights in action: A model program for executing successful and sustainable value-based agreements. Managed Healthcare Executive. 2026 Feb 9;36(2) https://www.managedhealthcareexecutive.com/view/real-world-insights-in-action-a-model-program-for-executing-successful-and-sustainable-value-based-agreements
  2. Mahendraratnam N, Sorenson C, Richardson E, Daniel GW, Buelt L, Westrich K, et al. Value-based arrangements may be more prevalent than assumed. The American Journal of Managed Care. 2019 Feb 13;25(25) https://www.ajmc.com/view/valuebased-arrangements-may-be-more-prevalent-than-assumed
  3. Gettings D, Visaria J, Sefain H, Grevenitz C, Cziraky M, Null K. Finding value in value-based agreements: a real-world success story. Managed Healthcare Executive 2022 Aug;32(8) https://lp.HealthCore.com/rs/621-UKX-708/images/MHE2022_VBA-article-Finding-value-value-based-agreements.pdf?version=0
  4. Garrison Jr LP, Carlson JJ, Bajaj PS, Towse A, Neumann PJ, Sullivan SD, et al. Private sector risk-sharing agreements in the United States: trends, barriers, and prospects. The American Journal of Managed Care. 2015 Sept 15;21(9) https://www.ajmc.com/view/private-sector-risk-sharing-agreements-in-the-united-states-trends-barriers-and-prospects