1 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

2 USA

3 Health care quality is inconsistent 6-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 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

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 6

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 7

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." 9

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 10

11 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 12

13 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 14

15 Step 2: Set a goal TodayThe 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 16

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 19

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 20

Breast Cancer Risk: New England Women w/Dense Breast Tissue & Negative Mammogram 22

Budget Impact of Supplemental Screening with MRI 23

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 24

25 Thank you Steve Pearson