Document 287487
Transforming Health Care: Using Evidence in Benefit Decisions Leah Hole-Curry, HTA Program Director Washington State Health Care Authority IOM Essential Benefits – February 2011 The State Budget, Health Care, and National Health Reform Budget Shortfall 2009-2011 – $2 Billion (of $33 Billion) – Past 3 years, total of $5.1 Billion in cuts to state budget – Federal funds of about $500M anticipated; $300M Medicaid – Preparing for a 4-7% across the board cut by October 2010 Projected shortfall for 2011-2013 is $3 billion Total health care spending now about 1/3 of state budget, was about 1/5 in 2005 – Waiver request to sustain BHP, Medical Care Services programs – Executive order to consolidate Medicaid, public employees health purchasing, eventually all state health purchasing, under HCA – Executive implementation of NHR, Joint Legislative Select Committee on Health Reform Implementation Low income expansion Health insurance exchange Health care workforce 1 The Budget and Health Care Washington State In FY2010 WA spent nearly $7 billion State General Fund to provide medical coverage to 1.5 million Washington residents … about 33% of the budget. In 2006, WA state spent $4.5 billion on health care; Up from $2.7 Billion in 2000 (a rise from 20% to 28% of budget) National Trends In 2007, total health care spending 15% of gross domestic product compared to just 4% in 1960 – Real per capita spending on health care grew an average of 4.2 percent annually; real per capita GDP grew at 2.2 percent Private Sector Trends Average annual insurance premium 7.3% increase over last 20 years (Mercer) For small businesses, increase is greater than the increase in wages or gross business income, some years by a factor of five Outpaces wage and overall inflation increases averaging approx 3% annually 2 What Accounts for Health Care Cost Growth? CBO Long term Health Care Cost Outlook 2007 Most analysts agree that the most important factor contributing to the growth in health care spending in recent decades has been the emergence, adoption, and widespread diffusion of new medical technologies and services. 3 ConsumerReports.org 10 overused tests and treatments November 2007 1 BACK SURGERY. … surgery, which can cost $20,000 plus physician's fees ….. 2 HEARTBURN SURGERY. operation, costs $14,600 or more 3 PROSTATE TREATMENTS. . over treated with surgery that costs $17,000, or by radiation therapy for $20,700 4 IMPLANTED DEFIBRILLATORS. … cost some $90,000 over a lifetime. 5 CORONARY STENTS. Billions are spent each year…. 6 CESAREAN SECTIONS. ..cost almost $7,000, about 55 percent more than natural delivery... 7 WHOLE-BODY SCREENS. CT scans, which can cost $1,000 … no proven benefits for healthy people. A few CT scans a year can increase your lifetime risk of cancer. 8 HIGH-TECH ANGIOGRAPHY. Using a CT …costs an average of $450...standard angiography is sometimes still needed. 9 HIGH-TECH MAMMOGRAPHY. Using software to flag suspicious breast X-rays would add $550 million a year to national costs if used for all mammograms. But a 2007 study found that this technique failed to improve the cancer-detection rate significantly, yet resulted in more needless biopsies. 10 VIRTUAL COLONOSCOPY. …Though less costly than a standard colonoscopy, the virtual test isn't cost-effective because any suspicious finding requires retesting with the real thing. Copyright © http://www.consumerreports.org/cro/health-fitness/index.htm 2000-2006 Consumers Union of U.S., Inc. 5 Goal: Find and Pay for What Works Proven Effect for Better Health Cost Proven Safe Effective Estimates range from only 4% to 53% of health care interventions have strong evidence to support them. (IOM, CBO, Lancet) No reliable evidence No reliable Evidence High Cost Or Ineffective Or Unsafe vs. alternatives Well-designed, well-conducted studies of the effectiveness of most health care services are the exception, and the available research evidence falls far short of answering many questions that are important to patients and providers. IOM: Knowing what works. 2008. 6 Evidence Based Health Care Cutting edge programs that have become part of our offerings: – Prescription Drug Program Preferred drug list used by PEBB, Medicaid, and workers compensation programs – Drug Purchasing Consortium Pooling of state and private purchasing power, used by PEBB & workers compensation – Health Technology Assessment State pays for procedures and medicine that show evidence of efficacy, cost-effectiveness, and safety Estimated savings of $27 million since 2007 – Patient decision aid pilot Focus on high-variation, preference-sensitive areas that involve multiple options and tradeoffs, e.g. cardiac disease; breast & prostate cancer – Opioid Dosing Guidelines – Medical Necessity Language tied to Evidence Rating – Advanced imaging management Using evidence based guidelines, identify highest cost/utilization advanced diagnostic imaging services for state programs 7 HTA Program Elements 1. HCA Administrator Selects Technology Nominate, Review, Public Input, Prioritize Semi-annual 2. Vendor Produce Technology Assessment Report Key Questions and Work Plan, Draft, Comments, Finalize 2-8 Months 3. Clinical Committee makes Coverage Determination Review report, Public hearing Meet Quarterly 4. Agencies Implement Decision Implements within current process unless statutory conflict 8 Evidence for use in Policy Decisions Different Data Sources Efficacy – How technology functions in “best environments” Randomized trials-distinguish technology from other variables Meta-analysis Effectiveness – How technology functions in “real world” Population level analyses Large, multicenter, rigorous observational cohorts (consecutive pts/objective observers) Safety – Variant of effectiveness Population level analyses Case reports/series, FDA reports Cost – Direct and modeled analysis Administrative/billing data (charge vs cost) Context – Mix of historic trend, utilization data, beneficiary status, expert opinion 9 HTA Measures and Outcomes Transparency – Topics, Key Questions, Draft Reports, Final Reports, Criteria Posted – Average 83 days of public comment per technology – 13 public meetings – all deliberations open Technology Reports: Analysis completed – Over 9,000 articles/trials reviewed – 19 comprehensive technology assessment reports Independent Coverage Decisions – 19 decisions where reliable evidence: 10 show benefit and support coverage for certain situations 8 do not yet show benefit and are not covered 1 shown unsafe or ineffective – Estimated $30 million cost avoided – Utilization impact: 3 increased; 6 same; 10 decrease 10 HTA Measures WA HTA Comparison with Insurer Policies WA HTA Topic Private Insurer Date Coverage Decision Aetna Regence-BC NCD No decision Same Same No decision No decision Same Same n/a No decision Ped Bariatric Surgery <18 Aug-07 Not covered Less Restrictive Less Restrictive Same BCBS TEC Premera-BS May-07 Not covered Less Restrictive Conditional Medicare Group Health Upright MRI Ped Bariatric Surgery 18-21 Reference Sources Same Less Restrictive Less Restrictive Less Restrictive Same Lumbar Fusion for DDD Nov-07 Conditional More Restrictive No decision Same Same No decision # No decision Discography for DDD Feb-08 Not covered Less Restrictive Same No Decision No decision No decision No decision Same Same Same Same* Less Restrictive Virtual Colonoscopy (CTC)Feb-08 Not covered Cancer screening Same* Summary Comparison of HTA Decisions and Private Insurers: Same as Private (some occur before, some after) - 47% Private Insurer is Less Restrictive - 22% Private Insurer is More Restrictive - 9% Private Insurer does not have published policy - 18% 11 Thank you! Additional resources: HTA: http://www.hta.hca.wa.gov/ PDP: http://www.rx.wa.gov/ Discount Card: http://www.rx.wa.gov/discountcard.html AIM: http://www.hta.hca.wa.gov/aim.html PDA/SDM: http://www.informedmedicaldecisions.org/washington_state_legi slation.html Joint Select Committee: http://www.leg.wa.gov/jointcommittees/HRI/Pages/default.aspx Governor Gregoire: http://www.governor.wa.gov/priorities/healthcare/reform.asp 12
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