Ashley Jaksa, MPH and Natalie Schibell, MPH
Recognizing the Role of RWE in Payer Decision-Making
U.S. payers have long acknowledged the value of real-world evidence (RWE), particularly its ability to fill critical evidence gaps left by randomized controlled trials (RCTs). For managed care organizations, RWE can illuminate real-world effectiveness, adherence trends, comparative performance, and total cost of care across diverse patient populations.
Despite this potential, the integration of RWE into formulary reviews and coverage assessments has historically been limited. In an evaluation of 27 therapeutic class reviews and monographs, only 21 RWE studies were cited among 565 total references—less than 5% of the evidence base presented to pharmacy and therapeutics (P&T) committees.
Still, the appetite exists: 89% of payers agree that RWE should be used alongside RCTs when making decisions. The challenge now lies in ensuring consistent quality and evaluation standards.
The question has shifted from why to use RWE to how to do it consistently and credibly.
Defining a New Standard for Managed Care RWE
To meet this need, the Academy of Managed Care Pharmacy (AMCP) Research Institute launched the Real-World Evidence Initiative in 2024. The effort brings together health plans, integrated delivery networks (IDNs), pharmacy benefit managers (PBMs), life sciences companies, and RWE methodologists to define where RWE fits in managed care and what constitutes high-quality evidence.
Key deliverables from the initiative’s first year included:
- Payer engagement survey: A targeted effort to understand current barriers to RWE adoption and the prerequisites for scale.
- Comprehensive literature review: A synthesis of methodological guidance and case studies informing payer use of RWE.
- Stakeholder focus groups: Sessions with payers and pharmaceutical representatives to validate findings and refine standards.
- Drafting of formal RWE Standards: A framework outlining how RWE should be evaluated and where it can be used within the formulary decision process.
- Partnership Forum: In November 2024, AMCP convened multi-stakeholder experts to review and refine the proposed standards. The outputs from this forum are being reviewed for inclusion in the AMCP Format for Formulary Submissions.
Building Capacity for Practical Implementation in 2025
With the foundational framework in place, the RWE Initiative now enters its second phase: ensuring that payers can apply these standards in practice. The 2025 agenda includes:
- Payer education and training: A series of RWE 101 and 201 programs to build internal capacity to evaluate and apply RWE across access, reimbursement, and population health teams.
- Best practice dissemination: Clear guidance for interpreting study design, data quality, and analytical methods to ensure consistency across therapeutic areas.
- Launch of an FDA-aligned RWE repository: A centralized database to support easier access to fit-for-purpose, high-quality RWE—improving transparency and operational efficiency.
These efforts are designed to elevate the system as a whole, giving health plans of all sizes a clearer path to incorporating decision-grade RWE into their standard workflows.
Demonstrating What’s Possible With Horizon BCBS and Aetion
Horizon Blue Cross Blue Shield of New Jersey offers a clear example of how real-world evidence can move beyond theory and into practice. In 2018, Horizon partnered with Aetion® to analyze its medical and pharmacy claims data to identify treatment pathways for members with Type 2 Diabetes. Using advanced analytics and real-world data, the collaboration produced a predictive model that helped pinpoint high-risk patients and determine which interventions would most likely improve outcomes.
One of the key findings was that shifting certain members to SGLT2 inhibitors—despite their higher cost—could yield better results than other second-line therapies. Horizon used these insights to launch a targeted case management program for 1,500 members with diabetes. The initiative was expected to improve health outcomes and reduce avoidable utilization, with projected savings of $5 million annually.
Encouraged by the results, Horizon expanded the partnership to additional therapeutic areas, including inflammatory bowel disease, COPD, asthma, and immunologic conditions. Insights from the collaboration informed Horizon’s value-based agreements with manufacturers and advanced its broader efforts to align care delivery with measurable, real-world outcomes.
Generating Published Evidence to Support Cost and Quality Strategies
In addition to direct payer collaborations, Aetion contributes to the scientific literature shaping population health and reimbursement strategy. In a published study co-authored by Aetion co-founder Sebastian Schneeweiss, M.D., Sc.D., researchers analyzed real-world data from a large U.S. health plan to understand drivers of total cost of care among members with Type 2 Diabetes.
The analysis found that just 20% of members accounted for 79% of paid costs, largely driven by inpatient utilization. These findings enabled targeted strategies to improve care and reduce avoidable spending, illustrating how stratified RWE can inform clinical and financial planning.
Supporting the Practical Application of RWE in Managed Care
As payers work to incorporate real-world evidence into routine decision-making, the need for structured, scientifically sound tools has become clear. Aetion partners with health plans to produce fit-for-purpose studies and to build internal infrastructure that enables sustainable use of RWE.
The Aetion Evidence Platform® supports transparent, reproducible analyses designed to meet the evidentiary standards of regulators, manufacturers, and payers. In parallel, our scientific team works directly with managed care organizations to:
- Review and evaluate externally submitted RWE studies
- Design internal analyses that address specific coverage or contracting needs
- Determine methodological fit and data readiness for key use cases
- Build internal capabilities to interpret and apply RWE in formulary and access workflows
In 2025, Aetion also contributed to AMCP’s educational programming at the Annual Meeting in Houston, Texas—part of our broader effort to support system-wide readiness and evidence fluency.
Start a Conversation About Your RWE Strategy
As a contributor to AMCP’s RWE Initiative and a partner to leading health plans, Aetion remains committed to accelerating the use of real-world evidence in payer decision-making, aligned with our mission to generate meaningful, data-driven impact across the health system.
RWE is no longer experimental—it’s becoming foundational. Whether you're building your internal RWE strategy or looking to generate decision-ready evidence for payer engagement, Aetion brings the tools, expertise, and scientific rigor to support your goals.
Schedule a consultation to explore how Aetion supports payers in implementing structured, scalable RWE solutions.