The Role of Purchasers and Payers in the Clinical Research Enterprise Workshop Summary (2002) / Chapter Skim
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2 The Role of Payers in the Clinical Research Enterprise
2 The Role of Payers in the Clinical Research Enterprise
Pages 29-50
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From page 29... ...
Workshop Co-Chair Senior Vice President and Chief Medical Officer Blue Cross and Blue Shield Association Two separate but distinct themes have emerged during the first part of the workshop regarding issues faced by purchasers, and each has different implications for the Clinical Research Enterprise. One theme is the notion of following best practices, following clinical guidelines, and reducing variations in care when the best thing to do is actually known.
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WHAT PAYERS NEED FROM THE CLINICAL RESEARCH ENTERPRISE Eric Book, M.D. Chief Medical Officer Wellmark Wellmark Blue Cross Blue Shield is a mutual insurer, predominantly in Iowa and South Dakota.
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Knowledge of community preventive health is lacking. Few research funds are channeled to health promotion and disease prevention relative to the funds spent for treatment.
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Reed Tuckson, M.D. Chief Medical Officer United Healthgroup United Healthgroup is among the largest of the national health care insurers.
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33 Greater leadership is needed to help coordinate and focus research activity in a climate of limited resources. Reed Tuckson The process of prioritizing and funding research projects today is not systematic.
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In addition to health benefits, Aetna offers dental benefits, vision benefits, life insurance, disability benefits, global health- and other health-related benefits. Its top clinical research priorities are to identify interventions, particularly at the health plan level, that are effective in improving health outcomes and in making more efficient use of health resources (by reducing costs while maintaining or improving health outcomes)
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Evidence-based clinical practice guidelines and consensus statements have often been used by health plans in making coverage decisions. Cost-effectiveness analyses have only been applied to primary clinical preventive services.
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Health plans also provide an infrastructure to support improvements in care that is otherwise lacking in the American health care system. They have a large interest in clinical trials.
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WHAT PAYERS ARE WILLING TO CONTRIBUTE TO THE CLINICAL RESEARCH ENTERPRISE Robert McDonough, M.D. Health plans can contribute to the Clinical Research Enterprise by directly funding research.
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Aetna distributes tens of thousands of continuing medical education monographs to its physicians, and it provides financial incentives to physicians to participate in continuing medical education. It distributes clinical practice guidelines that are based on evidence-based guidelines of medical professional organizations, and preventative structure guidelines that are based on the work of the U.S.
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Many health plans cover routine care costs for patients who are enrolled in clinical trials. Medicare and many health plans cover Category B investigational devices, which involve incremental modifications to established devices.
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. Heart disease, diabetes, and depression · Obesity and its prevention Promotion of physical activity in the population · Elimination of smoking · Development of a system of prevention, health promotion, and clinical care Development of community and population approaches to improving the members' health · Development of methods for improving patient safety and avoidance of errors in care Applying methods of care known to be effective and eliminating unsafe and ineffective care RESEARCH PRIORITIES AND PRIORITY SETTING FOR PAYERS Myron Genel of Yale University School of Medicine began the discussion of research priorities by pointing out that many of the points made about translational blocks earlier in the workshop concerned the second translational block, putting clinical research into practice, rather than the first block, translating basic research into clinical research.
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The RWJ Foundation funds, as does AHRQ and others, the work of many investigators who want to answer the kinds of questions purchasers and payers raise; yet investigators find that task challenging because the world is changing in a chaotic way that does not allow asking and answering questions or testing hypotheses. Sandy asked purchasers and payers: when you make changes in your system, would you consider using random assignment or quasi-experimental designs that would allow health services and outcome researchers to ask and answer questions and provide you with the answers that you say you would like?
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A payer's main purpose, as suggested by George Isham of HealthPartners, is to provide affordable health care to as many people as possible and, as a delivery organization, to provide what is known to be good health care as efficiently and effectively as possible with the highest satisfaction. The main purpose is not necessarily the discovery of new knowledge.
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Payers also need to understand the costs and benefits associated with disease management programs that help physicians do more than they can individually to provide preventive care and continuing care services for chronic diseases. George Isham noted that accompanying the decrease of uncompensated care is the increasing use of cost accounting mechanisms to justify the implementation of programs.
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Hal Slavkin of the University of Southern California School of Dentistry called for including a broader set of stakeholders if large gains are to be made in improving quality of life, reducing incidence of disease, and decreasing health disparities. He noted that we may miss a critical opportunity to include those who influence prenatal care and K-12 education in this country if we just use terms such as risk assessment, disease prevention, and health promotion.
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For instance, the low-fat diet that has been promoted as beneficial for the heart, has been misinterpreted by the public, leading to a major increase in consumption of carbohydrate, causing obesity and diabetes. Allan Korn of the Blue Cross Blue Shield Association mentioned that the FDA has a good process for the adoption of new drugs.
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Francis Chesley of the Agency for Healthcare Research and Quality noted in response that the government role is not sufficient and that partnerships are essential. The Agency for Healthcare Research and Quality, under its previous name the Agency for Healthcare Policy and Research, had the charge to bring clinical practice guidelines to the fore.
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From page 47... ...
George Isham noted that the more that consumers are faced with competing information and competing clinical trials in which to participate, the greater will be the need for transparency with respect to the Internal Review Board proceedings, the benefit of the research intervention, and the options available outside of the research trial. Consumerism is often equated to paying the bill, in the sense that there are more co-pays.
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SUMMARY The goal of the session on the role of purchasers in the Clinical Research Enterprise was to elucidate how the Clinical Research Enterprise can better serve payers as they strive to provide affordable health care coverage to as many people as possible, provide best evidence-based health care efficiently and effectively with the highest satisfaction, and contribute to health care research. Representatives from health plans (Wellmark Blue Cross Blue Shield, Health Partners, United Healthgroup, and Aetna U.S.
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They acknowledged the shift toward greater participation of consumers in their own health care and explored means for enhancing consumer education. Finally, they addressed the concern that health care plans may present barriers to patient participation in clinical trials.
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so ROLE OF PURCHASERS AND PAYERS
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Key Terms
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