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Beyond coverage decisions:

Private health plans in the US and comparative effectiveness research

Steven D. Pearson, MD, MSc, FRCPSteven D. Pearson, MD, MSc, FRCPPresident, Institute for Clinical and Economic ReviewPresident, Institute for Clinical and Economic Review

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USA

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Health care quality is inconsistent6-Fold Variation in Age-Adjusted Coronary Interventional Procedures

Source: Wennberg et al, Dartmouth Atlas of Health Care

CER and the Seven Habits of Highly Effective Active

Purchasers1. 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

Purchasers1. Narrow your network2. Change the system of care for the 1% and

the 5%3. Make prices a priority4. Contract differently to change the dynamic with

providers5. Develop better evidence on what really works6. Use “active” coverage policies linked to

evidence7. 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 real-world 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• 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

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

Step 1: Document substantial variation

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Step 2: Set a goal

Active surveillance

Brachytherapy

IMRT

Surgery

Proton beam

0%

20%

40%

60%

80%

100%

Patient Management Selection

Active surveillance

Brachytherapy

IMRT

Surgery

Proton beam

0%

20%

40%

60%

80%

100%

Patient Management Selection

Today The Goal: 100% Shared Decisions

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

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CER and the Seven Habits of Highly Effective Active

Purchasers1. Narrow your network2. Change the system of care for the 1% and

the 5%3. Make prices a priority4. Contract differently to change the dynamic with

providers5. Develop better evidence on what really works6. Use “active” coverage policies linked to

evidence7. Use evidence as a catalyst for collaborative

efforts to improve value

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Thank you

Steve Pearsonspearson@icer-review.org