When a VBA Fails at the Final Hurdle: Lessons from a Stakeholder Oversight
Everyone wants value-based agreements (VBAs) that work—not just in principle, but able to deploy and operationalise in practice. But here’s the reality: no matter how well-designed your VBA, your contract will stall if key stakeholders aren’t fully on board.
In this article, you'll gain practical insights into how genuine stakeholder engagement shapes the success—or failure—of a VBA. Whether you're in pharma, payer policy, or clinical leadership, you'll come away with a clearer view of where engagement efforts usually fall short, what better looks like, and how to move from token involvement to true partnership. It’s not about adding another task to the checklist—it’s about shifting how and when people are brought into the process.
What Happened
This was a value-based agreement (VBA) based in rheumatology with a bioloical medicines that seemed to tick all the boxes...
Payer engagement? Secured.
Manufacturer alignment? Check.
Measurable outcomes? Locked in.
But when it came time to implement, the entire agreement fell apart. Why? The physicians pushed back. They hadn’t been involved in designing the agreement, and the proposed outcomes didn’t reflect their clinical priorities or day-to-day workflow. Without their buy-in, the agreement was unworkable.
This case is not unique. It highlights the uncomfortable truth that even the most technically sound agreements can fail without meaningful, early engagement from all key stakeholders—especially the ones tasked with delivering outcomes...
1. Don’t Mistake Payer Buy-In for Full Alignment
Just because a payer has agreed to a VBA doesn’t mean the job is done. Too often, pharma teams treat payer approval as the final hurdle, assuming the rest will fall into place. But payer endorsement is just one piece of the puzzle.
What’s often missing is shared ownership. Agreements that are co-developed—with open discussions about administrative burden, clinical relevance, and data feasibility—tend to go further. True alignment isn’t just about contract terms; it’s about trust and mutual understanding.
2. Engage Physicians as Stakeholders, Not End-Users
Physicians often carry the operational burden of VBAs, yet are rarely part of the design. In this case, outcomes were selected that looked robust on paper but didn’t reflect clinical workflows or what physicians considered meaningful change.
When engagement comes too late—or not at all—physicians become blockers. But when their perspective shapes the contract early on, they become enablers. The key is making the contract feel intuitive from a clinical standpoint. If it aligns with good care, and all the voices are listened to in a meaningful way, then success for deployment welcomes.
3. Start with People, Not the Paperwork
VBAs are complex. They involve legal, clinical, commercial, and operational elements. But before diving into contract structures or data frameworks, it pays to map out the human stakeholders involved.
Who will need to say yes? Who will actually deliver on the agreement? And who might resist it? Bringing these voices in early can smooth out the deployment process and surface practical concerns before they become blockers.
4. Engagement is a Skill—Not Just a Step
Successful engagement isn’t about running one meeting and ticking a box. It requires structured dialogue, sensitivity to stakeholder priorities, and timing.
Go too early, and you risk vague conversations. Go too late, and it feels imposed. The most successful projects build engagement into the project timeline, allowing time for ideas to evolve in partnership—not under pressure. Remember to pressure test for all sides and adapt for different payer archetypes. Integrate your own commercial red lines and then use some of the advanced thinking to begin an exercise in co-creation and deployment of your VBA.
Summary & Key Takeaways
A technically strong VBA is not enough—physician alignment can make or break implementation.
Co-design with payers creates buy-in—co-design with clinicians ensures deliverability.
Ask early: are these outcomes clinically intuitive and operationally feasible?
Engagement needs planning, pacing, and follow-through—not just good intentions.
Start with people. Then build the contract—patient pathways is a good starting point.
The case described here—and the missteps it illustrates—isn’t an anomaly. It’s a pattern we see repeated too often, and one we need to collectively break. Innovative contracting strategy must be grounded in reality and built with those who will carry them forward. If you’re shaping access strategy—whether for a global launch or a local pilot—this is the time to revisit how you approach engagement. Not as a checkbox, but as a foundation.
Start earlier. Ask better questions. Listen harder. And above all, design with—not just for—those who’ll make it happen. The biggest predictor of success in deployment of VBA is...... previous deployment of VBAs. So get started!
Omar Ali,
Head of Payers, Verpora
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These reflections draw from a two-part discussion in our bite-size chat series. You can watch the full conversations for a deeper dive into what good looks like when it comes to stakeholder alignment…
About the Author
Omar Ali
Head of Payers, Verpora
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It takes a payer to know a payer’s mind, and Omar’s long experience puts him in an ideal position to unlock critical payer insights. A previous pharmacy & therapeutics payer and adviser to the UK national HTA appraisal body NICE, Omar’s experience encompasses the managed entry of new medicines and health technology appraisals with a deep knowledge of market access, pricing, reimbursement and health economics. For Verpora, Omar manages a global team of experienced pharmacy payers who bring in-depth insights to product value propositions and validation of market access strategy across international launch sequence portfolios. Omar is presently studying for his PhD in Value-Based Contracting.
Disclaimer
Content in this article is based on secondary market research using externally sourced data available in the public domain. Opinions and commentary are those of the authors and do not reflect views of any commercial organisation or government body mentioned in the article. For any questions relating to the article please contact omar.ali@verpora.com
