Using Evidence to Design Benefits
National Health Policy Conference
February 9, 2010
Washington, D.C.
Sam Nussbaum, M.D.
Executive Vice President, Clinical Health Policy and
Chief Medical Officer
Key Drivers in Value-Based Care
Establishing the
Evidence Base
Encourage ValueBased Decisions
Develop Value-Based
Benefit Designs
Safety and Quality
Drives Value
Science-based policy and
determining what works
Inform on appropriate
alternatives; close gaps in care
Benefit structure, incentives,
and increased management
Emphasize drug, device, and
medical safety
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Establishing an Evidence-Base:
Medical Policy
• Medical policies promote evidence-based care and proven science
• Continuous review of peer-reviewed medical research
• Engage 33 medical specialty societies and academic medical centers
• Apply published standards and considers community practice patterns
• Available on WellPoint website; http://www.anthem.com
ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES
3
Outcomes Research and Comparative
Effectiveness Research
“Real World” Research Drives Quality, Cost Effective Care
• Integrated data sources for outcomes research and analysis
• Collaborative research relationships with premier academic centers
• More than 110 research projects underway
• Breast cancer, asthma, rheumatoid arthritis, low back pain, multiple sclerosis
4
WellPoint Position:
CER Promotes Value and Innovation
Collaboration amongst health care system stakeholders
is central to making CER work
• Address unsustainable health care costs
• Limited resources threaten innovation
SUPERIOR
• Help patients choose more effective treatments
• Fewer unnecessary services = health system savings
COMPARABLE
• Quality first, then affordability
• Superior treatments deserve our nation’s investment
• Comparable treatments should be chosen on value
PERSONALIZED
• Selectively effective personalized treatments should be
managed by physicians and patients
• Remove inappropriate/ineffective treatments
INEFFECTIVE
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Emerging Medical Technologies and
Comparative Effectiveness
Diagnosis and Treatment of Prostate Cancer is Controversial
$ Dollars (thousands)
100
80
Even among radiation
treatments, there is variation
in cost and potential outcomes
60
40
20
0
3 -D
C o n fo rm a l
B ra c h y th e ra p y
IM R T
P ro to n B e a m
Comparative effectiveness can assess outcomes, quality of life, and survival
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Comparative Effectiveness:
STATINS
• Examined evidence for therapeutic substitution of
generic simvastatin versus name brand medications
• Results:
• 63% of all members could be appropriately treated with
generic simvastatin
• Encouraged appropriate use of generic simvastatin
through member/provider educations and incentives
• Cost savings to members through lower co-payments
Opportunity for add-on analyses of cardiac outcomes;
ultimate goal of statins is to prevent cardiac events
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Comparative Effectiveness:
ASTHMA CONTROLLER MEDICATION
• Clinical trials established inhaled
steroids as most effective treatment
• Convened national experts to study
“real world” experience of 56K
members
$1,300
Predicted 12-month Total Cost
$1,200
$1,100
$1,000
• Findings on oral medication use
$900
• Higher compliance
• Reduced asthma-related emergency
room visits and hospitalizations
ICS
8.5
LABA
LM
% Members With IP/ER Utilization
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• Higher over-all cost due to cost of drugs
7.5
• Singulair® moved to more favorable
tier, prior authorization removed
• Best outcomes from compliant,
combination prescription therapy
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6.5
6
ICS
LABA
LM
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Comparative Effectiveness:
Treatment Options and Risks/Benefits
• Facts on Back Pain
• 9 of 10 Americans experience back pain
• #1 cause of lost work productivity
• Most pain resolves within 6 weeks independent of treatment
• Study of 172,000 Anthem Members in 6 States
• 1,000 surgeries during first 6 weeks
• 35,000 imaging procedures within first 6 weeks
$$ COST $$
• $90B spent nationally on treatment
• Care dependent on initial treating physician
• Value and Benefits
• Collaboration with American Academy of Family Physicians
• New payment models including bundling of payments
• Educate members/physicians on treatment options
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Encouraging Appropriate Generic
Substitution
• GenericPremium® Benefit Design
• 20% cost reduction from all-generic
formulary plus the 1-2 most popular
branded drugs per drug class
• Physician office generic drug
dispensing kiosks (MedVantx)
• Generic co-pay waivers
Generic Dispensing Rates
80
75
70
65
60
55
• Member and physician education
2007
Commercial
2008
Medicare
2009
Medicaid
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Appropriate Sites of Clinical Service:
Case Study
Comparative Costs for Non-Emergency Diagnoses
$1000
Costs
Retail Health Clinic
Emergency Room
$500
Urgent Care
$0
Sinusitis
Pharyngitis
Otitis media
Bronchitis
Cold/flu/viral
Urinary infection
• Inappropriate ER visits result in higher cost, lower quality and risk to ER access for
true emergencies
• Nurse Hotline and on-line tools educate members on lower-cost alternatives
• Increased member liability for non-emergency ER use versus co-pay at
alternate/appropriate care settings
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Closing Gaps in Evidence-Based Care:
Informing the Patient
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Value-Based Networks:
Blue Distinction Centers of Excellence
• Improved quality through outcome
metrics
$45,000
$35,000
• Reduced complications
$25,000
• Programs
$15,000
• Transplant
Median Cost Per DRG Event
$5,000
AMI
• Bariatric Surgery
CABG
CABG+PCI
CABG Readmissions/Complications
• Cardiac Surgery
20%
• Rare Complex Cancer
• Orthopedics: Lower Back Pain
• Spine, Hip, and Knee Surgery
16%
12%
8%
4%
0%
Qualified facilities demonstrate
$4K - $9K lower costs per event
CABG Readmissions
CABG Complications
Non-Blue
Distinction
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Value-Based Benefit Design:
Northeast State Case Study
Preventive Outpatient Services
• Telephonic diabetes education and
support (TDES) program
80%
• Incentives for medication compliance
40%
• Waived diabetic medication/supplies co-pays
• Steered patients to higher quality hospitals and
physicians
60%
20%
0%
HbA1c
Eye exam
TDES
Nutrition & Weight Counseling
Control
• Preventive care exempt from deductible
• Higher overall cost during study period
$2,500
Pre/Post Study Utilization Costs
$2,000
• Longer term follow-up may
demonstrate savings due to:
• Higher medication compliance
• Higher utilization of preventive service
$1,500
$1,000
$500
$0
Outpatient
Pre‐TDES
Prescriptions
Post‐TDES
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WellPoint Safety Sentinel System:
Vioxx® Case Study
34 million members’ claims, pharmacy, and laboratory data
enables population safety and public health research
Signal Count
Serious
Adverse
Events
Analysis of our membership would have detected
increased cardiovascular events within 3-6 months after
FDA approval
Threshold
for Action to
Reduce or
Eliminate Patient
Exposure
Heart
Attacks
&
Strokes
Timeline
Jan 1998
Jan 1998
Vioxx® History
Hints of cardiovascular
issues in clinical trials
May 1999
May 1999
FDA
Approved
April 2001
April 2001
Sept 2004
Sept 2004
Vioxx
removed from Market
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Health.Care.Value
Promoting health care quality, safety, and affordability
through evidence-based care
Determine “what works” in
health care
Promote value-based
decisions through information
and education
Develop integrated,
incentive-based benefit
designs
Create quality metrics and
value-based networks
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