Leadership Commitments to Improve Value in Health Care Finding Common Ground: Workshop Summary (2009) / Chapter Skim
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11 Insurers
11 Insurers
Pages 269-296
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From page 269... ...
Other Contributors Carmella Bocchino, America's Health Insurance Plans; George Halvorson, Kaiser Permanente; Carmen Hooker Odom, State of North Carolina Department of Health and Human Services; Mark McClellan, AEI-Brookings; Leslie Norwalk, Centers for Medicare and Medicaid Services; Steve Udvarhelyi, Independence Blue Cross SECTOR OVERVIEW The Institute of Medicine's (IOM's) Roundtable on Evidence-Based Medicine seeks to transform the way in which medical evidence is generated and used to improve health care.
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From page 270... ...
, a trade association that represents the full spectrum of health insurance plans, and the Blue Cross and Blue Shield Association (BCBSA) , a licensing entity that represents those health insurance plans that are licensed to use Blue Cross and Blue Shield service marks in exclusive service areas.
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From page 271... ...
AHIP represents 90 percent of all the accident and health insurance business in the United States; and AHIP members include commercial insurance companies, most Blue Cross Blue Shield plans, managed care organizations, self-funded plans, PPO networks, third-party administrators, disease management organizations, and reinsurers. AHIP's goal is "to provide a unified voice for the health insurance industry, to expand access to high quality, affordable health care for all Americans, and to ensure Americans' financial security through robust insurance markets, product flexibility and innovation, and an abundance of consumer choice." The organization represents member interests on legislative and regulatory issues at the federal and state levels and with the media, consumers, healthcare professionals, and employers (America's Health Insurance Plans, 2004)
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From page 272... ...
Accompanying these rising healthcare costs and, many would argue, contributing to these costs is the fact that medical care has become notorious for wide regional variations in treatment, the significant underuse and misuse of recommended best practices, and an undue reliance on treatments of little or no value. Research has consistently shown that Americans receive healthcare services in accordance with the latest scientific evidence only about half of the time.
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From page 273... ...
In response, physicians, patients, and policy makers successfully lobbied state legislatures to pass legislation mandating that health insurance plans provide coverage for this treatment. It was not until 1999 that the preliminary results of five clinical trials for HDC/ABMT showed that the treatment was no better in extending survival than standard treatment and, in fact, posed higher risks of toxic side effects.
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From page 274... ...
These programs screened recommended care against evidence-based guidelines to reduce unnecessary variations in practice and to identify care that was inappropriate or unsupported by the medical evidence. However, pressure from consumers, providers, and legislators forced health insurance plans to significantly curtail their utilization management programs, which has led to continuing issues with healthcare quality and which has prompted health insurance plans to seek alternative ways to promote quality and cost-effective care.
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From page 275... ...
Despite the conclusion from a recent Congressional Budget Office analysis that it is too early to estimate the impact that disease management programs are having on overall healthcare spending, the market response to disease management suggests that health insurance plans and employers are finding that disease management provides good value. A national study that used data from a large health insurance plan in 10 urban areas found that overall costs were significantly lower for full-year program participants with diabetes than for nonparticipants with diabetes, and the purchasers of the disease management program saved more than was spent.
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From page 276... ...
Performance is measured by the use of selected evidence-based standards and performance measures as a method to potentially reverse the perverse incentives of current payment models that lack any recognition of quality performance. By aligning incentives to encourage improvements in patient care, some health insurance plans have already begun to see rising rates of preventive care and improvements in key indicators of patient health.
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From page 277... ...
Although the detractors of value-based purchasing and benefit design argue that decisions regarding healthcare coverage should not include costs, others point to the escalation of healthcare spending as an outcome of not considering cost in relation to the amount of additional benefits that new technologies and treatments can provide. Value-based purchasing and benefit design can help break the pattern of wasteful spending and increase the quality of the care provided by basing decisions on both clinical and costeffectiveness, without leading to all-or-nothing coverage decisions.
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From page 278... ...
The Drug Effectiveness Research Project (DERP) is a collaboration of public and private organizations, including 15 state Medicaid programs, that have joined together to share the cost of conducting systematic evidence-based reviews of the comparative effectiveness and safety of pharmaceuticals in many widely used drug classes.
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From page 279... ...
Furthermore, some state Medicaid agencies have established independent advisory entities that provide access to the latest evidence for policy decisions. Several state Medicaid programs have also undertaken innovative pilot efforts to improve the quality of care based on principles that originated in the private sector.
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Private health insurance plans may become more engaged with CED-type initiatives in the future to support this approach to evidence generation (Atkinson, 2007)
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From page 281... ...
LEADERSHIP COMMITMENTS AND INITIATIVES Strategies for Setting a Higher Bar: Improving Quality Through Better Generation, Dissemination, and Implementation of Medical Evidence Although the insurer sector has played a leadership role in the ongoing evolution toward a more value-based healthcare system, the quality, cost, and access problems that continue to plague the healthcare system clearly indicate that more can -- and must -- be done. Several innovative strategies merit expansion and adoption within the private and public sectors to further this evolution.
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From page 282... ...
One prominent example of the use of evidence-based recommendations is health insurance plans' approach to the coverage of preventive services supported by authoritative review of medical evidence by AHRQ's U.S. Preventive Services Task Force.
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From page 283... ...
Whereas the CEB will not be a federal agency, it must use the expertise and skills of the existing federal agencies to establish methodological standards for comparative research, conduct the necessary research, and help disseminate the results. As an interim and, in fact, complementary step, the capture of additional patient data in the course of clinical care for assessment of the appropriateness, utilization, and impact of particular healthcare services for which evidence may be lacking is another worthwhile strategy.
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From page 284... ...
Greater • investment is needed to help train clinical researchers to understand and adopt the findings of pragmatic or practical clinical trials. Study design along traditional lines is often taught to clinical researchers, but greater cross-fertilization from healthcare services research and from disciplines that employ quasiexperimental and qualitative research designs is needed because comparative effectiveness trials often cannot be randomized controlled trials because of practical and ethical constraints.
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From page 285... ...
Additionally, FDA's enforcement abilities should be expanded to better enable the agency to require drug manufacturers to make labeling revisions and to perform additional clinical trials to ensure postmarketing safety. Health insurance plans and employers can play an important role in integrating the results of these postmarketing studies by regularly updating their formularies and reimbursement policies to integrate the new data that may emerge as a result of those studies.
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From page 286... ...
One important benefit of this enhanced emphasis on the evidence gap will be to draw attention to the fact that a significant portion of modern medicine is not supported by medical evidence and that more work needs to be done to align current medical practices with medical evidence. In addition to identifying and promoting research in these priority areas, HHS's role should include enhanced communication with the public about those studies under way to address these priority areas.
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From page 287... ...
The private sector has led the way in developing a uniform approach to the disclosure of relevant, useful, understandable, and actionable information to facilitate consumer decision making. The key stakeholders among the different disciplines, including health insurance plans, physicians, hospitals, consumers, and employers, have convened broad-based, national alliances (AQA Alliance and HQA)
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From page 288... ...
Although some progress has been made, the proliferation of multiple, uncoordinated, and sometimes conflicting initiatives has had significant unintended consequences for different stakeholders. Duplicative efforts unnecessarily burden physicians, other clinicians, and health insurance plans with different data requests, shifting the focus away from quality and efficiency improvement.
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From page 289... ...
In addition to creating medical policies that reflect scientific findings on effectiveness and value, health insurance plans routinely provide information to patients encouraging them to receive preventive benefits supported by medical evidence. Health insurance plans have also capitalized on their ability to advance nationally recognized preventive services through their disease management and wellness programs.
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From page 290... ...
Invest in Infrastructure Development, Deployment, and Use The transparent collection, analysis, and dissemination of information on the latest medical evidence, performance, and comparative effectiveness at the point of care will require further investment in several key areas of the healthcare infrastructure. First, significant investment will be needed to build the early systems that can aggregate administrative data and electronic health record information in a reliable fashion.
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From page 291... ...
Collaboration among providers, insurance plans, consumers, purchasers, and manufacturers must increase to take advantage of these opportunities. Several specific areas in which continued progress would greatly benefit from enhanced collaboration between health insurance plans and other stakeholders are as follows: Efforts to develop benefit language compatible with medical • evidence-based innovative benefit designs (e.g., tiered benefits for procedures, devices, and diagnostics and incentives for con sumers to take up therapies supported by evidence)
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From page 292... ...
The development of a new format for technology appraisals that • allows the integration of ratings of clinical and cost-effectiveness that can support value-based insurance benefits and guide deci sion making by patients and clinicians toward higher value could benefit from collaboration among health insurance plans and other stakeholders and the Institute for Clinical and Economic Review. The exploration of further application of CED initiatives in cir • cumstances in which further evidence generation is needed to assess important remaining questions about the safety and comparative effectiveness of new technologies could be achieved through col laboration among CMS, health insurance plans, and other private sector entities, such as the Center for Medical Technology Policy.
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. America's Health Insurance Plans.
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2004. Effectiveness of a disease management program for patients with diabetes.
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2003. Can a disease self-management program reduce health care costs?
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