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Beyond coverage decisions:
Private health plans in the US and
comparative effectiveness research
Steven D. Pearson, MD, MSc, FRCP
President, Institute for Clinical and Economic Review
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USA
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Health care quality is inconsistent
6-Fold Variation in Age-Adjusted Coronary Interventional Procedures
Source: Wennberg et al, Dartmouth Atlas of Health Care
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CER and the Seven Habits of
Highly Effective Active Purchasers
1. Narrow your network
2. Change the system of care for the 1% and
the 5%
3. Make prices a priority
4. Contract differently to change the dynamic
with providers
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CER and the Seven Habits of
Highly Effective Active Purchasers
1. Narrow your network
2. Change the system of care for the 1% and
the 5%
3. Make prices a priority
4. Contract differently to change the dynamic with
providers
5. Develop better evidence on what really works
6. Use “active” coverage policies linked to
evidence
7. Use evidence as a catalyst for collaborative
efforts to improve value
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Develop better evidence
on what really works
• Comparative effectiveness research
– Research comparing alternative care options to
determine what works best for whom, under realworld conditions
– Systematic review of existing published evidence
• PBAC, NICE, etc.
– Generation of new evidence
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New partnerships to generate evidence
Generating and using CER
• Wellpoint, 2008
– REAL WORLD EFFECTIVENESS OF ASTHMA CONTROLLER
MEDICATIONS
• Analysis of claims data of more than 55,000 patients who had used
asthma controller medications found:
– Inhaled asthma medications could achieve the lowest rate of
emergency room visits and inpatient hospitalizations, but…
– Medication compliance was lower with inhaled medications than
with oral medications, particularly among children.
• August, 2009
– WellPoint said its National Pharmacy and Therapeutics Committee
"chose to keep the oral controller used by the vast majority of its
members on the same preferred formulary tier and lift its prior
authorization requirement."
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CER and the Seven Habits of
Highly Effective Active Purchasers
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Use “active” coverage policies linked to
evidence
–
Coverage with evidence development
•
•
•
–
PET for cancer
CT angiography
Drug eluting stents
Step edit policies
•
•
Higher value options not being used
Can limit by type of provider, number of doses, fail
other options first
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Using step edit policies
•
Adalimumab (Humira)
– “Prior approval is required for this drug”
– Restricted to rheumatology with a dose limit of
40mg every other week:
1) for patients with a dx of rheumatoid arthritis, AND
2) when prescribed by a rheumatologist, AND
3) For patients who have tried and failed or have medical
contraindications to methotrexate (at least a three
month trial)
– This specialty drug must be obtained through
SpecialtyScripts Pharmacy
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CER and the Seven Habits of
Highly Effective Active Purchasers
•
Use evidence as a catalyst for collaborative
efforts to improve value
–
–
•
The Project to Improve Prostate Cancer Care
The New England Comparative Effectiveness
Public Advisory Council
At the root of these initiatives are
independent, trustworthy reviews of
comparative effectiveness evidence
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The Project to Improve
Prostate Cancer Care
• ICER review of treatment options for low-risk
prostate cancer found
– Good evidence for active surveillance
– NO significant difference in outcomes between
radiotherapy approaches IMRT, brachytherapy, and
proton beam therapy with 3-5 times price differential
• Massachusetts coalition
– Purchasers (employers)
– Health plans
– Integrated Provider Groups
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Step 1:
Document substantial variation
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Step 2: Set a goal
Today
The Goal: 100% Shared Decisions
100%
100%
Proton beam
80%
60%
80%
Surgery
Proton beam
Surgery
60%
IMRT
40%
40%
IMRT
Brachytherapy
20%
20%
Brachytherapy
0%
Act ive
surveillance
0%
Patient Management Selection
Active
surveillance
Patient Management Selection
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Step 3: Align efforts
• Explored “active” coverage policy with prior
authorization or non-coverage but not feasible
• Explored changing prices paid but found prices
embedded in larger contractual arrangements
• So coalition decided to develop a common
patient decision guide as a community standard
• Health plans offered incentive to providers to
document shared decision-making with decision
guide
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http://prostateoptions.icer-review.org
The New England Comparative
Effectiveness Public Advisory Council
New England CEPAC
• Collaboration among
–
–
–
–
State health plans for the poor (Medicaid)
Private plans
Large physician-hospital groups
Patient groups
• Independent Council meets in public to discuss
evidence reviews on effectiveness and COST, to
vote on evidence, and to make recommendations
for best practice and policy
• All stakeholders work together afterward to
implement the findings
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New England CEPAC:
Topics and Impact
• Treatments for Attention-Deficit Hyperactivity Disorder
(ADHD)
– Shift to behavioral therapy for youngest children
• Treatment for severe depression
– First-in-nation coverage for magnetic treatment
• Diagnosis of sleep apnea
– Shift to home diagnosis (equivalent accuracy and lower cost)
• Community Health Workers
– Identified best practices for training and integrating into
health care teams
• Supplemental Screening for Women with Dense
Breast Tissue
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Breast Cancer Risk: New England Women
w/Dense Breast Tissue & Negative Mammogram
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Budget Impact of Supplemental
Screening with MRI
$2.0
$1.8
$1.6
Billions
$1.4
$1.2
$1.0
$0.8
$0.6
$0.4
$0.2
$0.0
All Women
High-Risk Only
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CER and the Seven Habits of
Highly Effective Active Purchasers
1. Narrow your network
2. Change the system of care for the 1% and
the 5%
3. Make prices a priority
4. Contract differently to change the dynamic with
providers
5. Develop better evidence on what really works
6. Use “active” coverage policies linked to
evidence
7. Use evidence as a catalyst for collaborative
efforts to improve value
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Thank you
Steve Pearson
[email protected]
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