Transcript Building Trust Through Rationing

Comparative Effectiveness Research:
Key Issues and Controversies
Consumer-Purchaser Disclosure Project Discussion Forum
May 5, 2009
Steven D. Pearson, MD, MSc, FRCP
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Background
• Policy givens:
– Unsustainable cost increases
– Unexplainable variation in practice patterns
– Not enough evidence for decisions about new treatments
• International efforts (health technology assessment)
– NICE in England
• “Comparative Effectiveness”
– Stark bill
– Baucus bill
• American Recovery and Reinvestment Act (ARRA) stimulus bill
funding for Comparative Effectiveness Research (CER)
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10-Year Impact on Spending
of a Center for Comparative Effectiveness
COSTS
Dollars in billions
$200
$100
$0
-$49.1
SAVINGS
-$100
-$113.6
-$200
-$97.7
-$107.1
Households
-$300
-$400
-$367.5
Systemwide
Federal
State and
Private
Gov't
Local Gov't
Payer
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
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Chief remaining questions on CER
• Stimulus spending
– Priorities for spending at AHRQ and NIH
– Secretary of HHS $400 million
– Inclusion of cost and/or cost-effectiveness
• CER 2.0
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Structure
Governance
Funding
Priority Setting
Research Methods (cost-effectiveness)
Implementation
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Stimulus spending
• Priorities for spending at AHRQ and NIH
– Mix of systematic reviews and prospective studies
– Framing of topics as “drug vs. drug” or broader
pathways of care
– Studies of health plan policies such as prior
authorization
• Secretary of HHS $400 million
• Inclusion of cost-effectiveness
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Weighing up costs and effects
Cost ($)
High extra cost
Low gain
New treatment
less effective, more costly
Low extra cost
High gain
Effectiveness
New treatment
more effective, less costly
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Why Costs?
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“Not to consider costs is delusional”
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Costs should be considered transparently and
always in the context of clinical effectiveness
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Without consideration of cost
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No societal support for explicit cost considerations in
clinical decisions and medical policies
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All explicit health plan efforts will be suspect
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Continued difficulty negotiating prices in relation to
evidence of incremental benefit
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Marginal benefit at high price will continue to be a
dominant market signal for manufacturers
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How to do Costs?
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Carve-out
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Arms’ length
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Commissioned by individual payers, including Medicare
Funded as part of CER stream but function delegated to an allied
yet separate organization
Carve-in
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Distrust of clinical effectiveness judgments if mixed with costs
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More efficient to nest within same effort to generate a systematic
review of the clinical evidence
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Benefits from the objectivity and transparency of a federal
comparative effectiveness initiative to gain broad acceptance
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Legislation for CER 2.0
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Structure
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Governance
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Who and how?
Research Methods
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How much from private health plans and purchasers?
Priority Setting
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Stakeholders on the Governing Board or only on Advisory
Committees?
Funding
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Inside or attached to government vs. independent?
Cost-effectiveness yea or nea?
Implementation
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http://www.politico.com/singletitlevideo.html?bcpi
d=1155201977&bctid=21157881001
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How will CE information be used?
• Concerns
– Limit access to life-saving treatments just because
of cost
• “One-size-fits-all” methodologies and applications to
coverage policies
• Cost-effectiveness applied as a strict cut-off for coverage
• Cost-effectiveness devalues older, sicker patients
– Put governmental bureaucrats between you and
your doctor
– Stifle innovation
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How CER should be used
• “Too cold”
– Dissemination of information to patients and clinicians
• “Too hot”
– Direct mandates for “all-or-nothing” coverage decisions
• “Just right”
– Providing “guidance” to patients, clinicians, and payers
– Application by payers to create value-based tools and
policies in support of optimal care and to ensure best use of
every health care dollar
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Patient-clinician decision support
Reimbursement policy
Value-based insurance design
Physician group compensation (P4P)
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Application of Cost-effectiveness
1. Help identify the least costly alternative among
equivalent treatment options
2. Provide some context for the additional cost paid for
very marginal clinical benefits
3. Help anchor initial pricing for new technologies in
evidence of their marginal (if any) benefit
• Tools
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Patient-clinician decision tools
Reimbursement policy
Value-based insurance design
Physician group compensation (P4P) to align incentives
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For further information:
[email protected]
www.icer-review.org
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