Sen. Bill Nelson is the primary sponsor of legislation to impose rebates on Medicare Part D. But when he held a hearing on the program in his Aging Committee, something surprising happened: everyone wanted to talk about adherence instead.

In theory, pay-for-performance (P4P) contracts could be highly desirable tools to address shifting dynamics of the pharma market, but, in practice, they’re likely to remain rare because they’re expensive and complicated to implement. Two recent, high-profile collaborations between pharma companies and payors in the US highlight growing interest in P4P arrangements, but experts are divided over whether they can be widely emulated.

Pharma companies are building long-term value propositions that should appeal to Accountable Care Organizations into some go-to-market strategies for new drugs and to repositioning efforts of already marketed drugs that have hit snags. The rationale might seem straightforward—for example, more convenient dosing that improves compliance and cuts down hospitalization rates--but the nuances can be complex. Moreover, even when their products appear to have compelling cases for value, companies have not by and large made ACOs a distinct target for their commercial operations.