Comparative Effectiveness
and Cost-Effectiveness:
Payer Perspectives
ARM Annual Meeting
June 29
29, 2010
Lewis G. Sandy M. D.
Senior Vice President, Clinical Advancement
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Overview:

Concepts: Clinical Efficacy
Efficacy, Clinical Effectiveness
Effectiveness, Comparative
Effectiveness, Cost-Effectiveness

Perspectives on Value
 What is Value?
 What do Payers Do with Information on Value?
 What is current state of knowledge of Value?

What is the Future State?
 Comparative Effectiveness Research
 Emerging Treatments and Therapies

Optimal Care: It’s More Than Just the Data
 Treatment Decision Support
 The Role of the Consumer
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Clinical Value of a Procedure, Device or Drug
The Payer Perspective

Does it ever work? How strong is the evidence?

What population of persons would benefit from a proposed treatment?

How a procedure,
procedure device or drug affects health outcomes?

Advantages, harms, alternatives

Clinical evidence of safety and efficacy

How does it work in the “real world”?
Payers vary, but in general:
Clinical Value affects coverage decisions
Cost-Effectiveness affects benefit level/structure
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UnitedHealthcare
Hierarchy of Clinical Evidence

Statistically robust, well-designed randomized controlled trials

Statistically robust, well-designed cohort studies

Large, multi-site observational studies

Single-site
Single
site observational studies

In the absence of incontrovertible scientific evidence, medical policies may be
based upon national consensus statements by recognized authorities. The
following stratification describes the hierarchy of use of medical policies and
clinical guidelines within UnitedHealthcare:
 Centers for Medicare and Medicaid Services (CMS) National Coverage Decisions
(NCDs) (Medicare population)
 Milliman Care® guidelines (commercial population)
 National guidelines and consensus statements, e.g. United States Preventive
Services Task Force (USPSTF), National Institutes of Health (NIH) clinical statements,
Agency for Health Care Research and Quality (AHRQ) clinical statements.
 Clinical p
position p
papers
p
of p
professional specialty
p
y societies,, e.g.
g American College
g of
Physicians (ACP), American College of Cardiology (ACC), American College of Chest
Physicians (ACCP), when their statements are based upon referenced clinical
evidence.

Expert
p opinion
p
At the end of the day we need more than an opinion, we need a decision
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What’s wrong
g with the current state?

Systematic reviews of clinical evidence and clinical practice guidelines often lack
scientific vigor
 Clinical evidence vs. consensus vs. expert opinion

Body of clinical evidence for services in which stakeholders are interested may
be weak or totally lacking
 Treatment of chronic wounds
 Non-surgical
N
i l ttreatment
t
t off uterine
t i fibroids
fib id

Difficult for stakeholder to connect recommendations to clinical evidence
 No nationally agreed
agreed-upon
upon method for rating evidence or strength of recommendations
 Bias and conflict of interest

Conflicting recommendations
 Treatment of Lyme disease
 Allergy immunotherapy
 Asthma
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Examples
p
of New or Emerging
g g Treatments
 CellSearch
CellSearch™
assay for circulating tumor cells
 Bevacizumab
to treat age-related wet macular degeneration
 Endovascular
repair of thoracic aortic aneurysm
 Multigene
 Hip
assays for treatment planning for breast cancer
resurfacing arthroplasty
 Endobronchial
 Bronchial
 Cervical
valves for lung volume reduction
thermoplasty to treat moderate-to-severe asthma
disc p
prosthesis for treatment of degenerative
g
disc
disease
New CER Infrastructure Needs to Account For
New/Emerging as well as Current Treatments
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The Center of the Health Care
U i
Universe:
Th
The Exam
E
Room
R

Health
H
l h care d
delivery
li
iis
most effective when
doctors and patients
make
k choices
h i
th
thatt are
 Informed by a rich
understanding of the
patient’s
ti t’ needs
d
 Supported by
evidence-based
medicine
di i
 Tracked by tools that
assure progress to the
d i d clinical
desired
li i l and
d
economic outcome
Health care transformation: synchronizing the system and its participants
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Treatment Decision Support Focus
Targets specific conditions, treatments for maximum
impact
Treatment variation for targeted condition (bubble size)
distributed by prevalence and cost per episode
Cost per Episode
e
$25,000
Bariatric
g y
surgery
Knee
replacement
$20,000
Back pain
$15,000
$10,000
Coronary disease, CABG
and angioplasty
Hip
replacement
Prostate
cancer
$5,000
Benign
prostate
disease
Breast cancer
Benign uterine
conditions, hysterectomy
$0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Prevalence (Episodes per 1,000)
Musculoskeletal
Back pain
Knee and hip
replacement
Men’s Health
Benign prostate
disease
Prostate cancer
Women’s Health
Breast cancer
Benign uterine
conditions,
hysterectomy
Heart Disease
Coronary disease,
CABG and
angioplasty
Obesity
Bariatric surgery
Cost  Prevalence  Practice Variation  Outcome Variation
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8
Treatment Decision Support
Condition
Education
“What do I have?”
Identify member needs
and preferences.
 Understand severity of
condition.
 Provide evidencebased information
about the condition.
 Provide assistance
with emotional support
surrounding the
diagnosis.
Treatment
Alternatives
“What are my
options?”
Provide a foundation for
decision-making.
 Explain relevant
decision points that
are unique to each
individual.
 Expand consideration
set with information
about
b t treatment
t t
t
alternatives.
Identify members through:
Target members who:
 Notifications
 Have a specific condition
 Predictive modeling
 Health coaching/NurseLine referrals
 Are considering surgical
treatment options
 Targeting promotions
Using:
 Case management referrals
 Rigorous rules for each
of the ID approaches
 Disease management
g
referrals
Right Facility
and Provider
“Where should I go?”
Provider and facility
referrals.
 Understand member
treatment preferences
for physician and
facility selection.
 Identify benefit
and health coverage
information.
 Refer members to
physicians and facilities
that meet quality and
efficiency standards
and to COE Network
facilities.
Programs include:
Musculoskeletal
 Back pain
 Knee and hip
replacement
Men’s health
 Benign prostate
disease
 Prostate cancer
Obesity
 Bariatric surgery
Admission
Counseling
“What should I
expect?”
Help members prepare
for treatment and
follow up care
follow-up
care.
 Answer questions about
the treatment, including
what to expect in the
course of care.
 Identify expected length
off stay, based on clinical
guidelines.
 Explain post-discharge
planning steps and
considerations.
Women’s health
 Breast cancer
 Benign uterine
conditions/
hysterectomy
Heart disease
 Coronary disease,
CABG and angioplasty
4
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Implications:

Clinical Effectiveness and Cost Effectiveness can (and should
should, in my
opinion) be separated

Need a robust national capability for Comparative Effectiveness
Research

Expect greater scrutiny and increased transparency for all actors in the
US health care system

“Value-based” benefits structures are a double-edged sword:
 A tailwind for therapies with higher clinical and economic value
 A headwind for therapies with lower value

Migration from highly subsidized consumer or physician preference to
facilitated optimal decision-making with varying cost implications
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