Transcript Document

Comparative Effectiveness Research:
Understanding What It Is and Helping to
Shape the Future Course
Debra Ness
Co-Chair, Consumer-Purchaser Disclosure Project
President, National Partnership for Women & Families
Peter V. Lee
Co-Chair, Consumer-Purchaser Disclosure Project
Executive Director, National Health Policy
Pacific Business Group on Health
Invitational Working Session
May 5, 2009
Agenda
Welcome and Introductions
– Debra Ness, Disclosure Project and NPWF
Setting the Context for Comparative Effectiveness Research
– Peter V. Lee, JD, Disclosure Project and PBGH
Overview of CER and Key Issues
– Steven Pearson MD, MSc, FRCP, Institute of Clinical and
Economic Review
Use of CER by CMS and Private Payers
– Sean Tunis MD, MSc, Center for Medical Technology Policy
Roundtable Discussion
– Peter Lee, JD, Disclosure Project and PBGH
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Problem 1: Much of Care Today is Not
Based on Scientific Evidence
Less than 20% of AHA/ACC heart disease management recommendations are based on a
high level of evidence and over 40% are based on the lowest level of evidence AND proportion
of recommendations with high evidence levels has not increased over time
Robert Califf, IOM Meeting on Evidence-based Medicine, December 2007
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Problem 2: When There Is Evidence, It Is
Frequently Not Followed…
Adherence to Quality Indicators
Regional variation in quality
and cost
75.7%
Breast Cancer
73.0%
Prenatal Care
Low Back Pain
68.5%
Coronary Artery Disease
68.0%
Hypertension
64.7%
Congestive Heart Failure
63.9%
57.7%
Depression
57.2%
Orthopedic Conditions
Colorectal Cancer
53.9%
Asthma
53.5%
Benign Prostatic Hyperplasia
54.9% = Overall care
54.9% = Preventive care
53.5% = Acute care
56.1% = Chronic care
53.0%
Hyperlipidemia
48.6%
Diabetes Mellitus
45.4%
Headache
45.2%
Adults receive about half
of recommended care:
40.7%
Urinary Tract Infection
32.7%
Ulcers
Hip Fracture
22.8%
Alcohol Dependence
10.5%
0%
20%
40%
60%
80%
100%
Percentage of Recommended Care Received
Avoidable harm: 99,000
deaths in hospitals from
health care acquired
infection
Overuse: 13 million
unneeded antibiotic RX
US: 10th in life
expectancy; 27th
in infant mortality
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…But We Do Know Following Evidence Can
Dramatically Improve Care
If care provided
nationally AS IT IS to
4 million Medicare
beneficiaries, we
could save 29% of
Medicare spending
If all health plans performed at
the NCQA’s 90th percentile –
over 40,000 lives would be
saved each year and over $2
billion
Thousands of hospitals
participating in the 5 Million Lives
Campaign – many hospitals
proving ZERO infections is
doable
WITH coordinated
care – risk of heart
disease mortality
reduced 30%
(example of Kaiser
No.Cal)
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Problem 3: Rising Costs Are Unsustainable for All
Projected Spending on Health Care as a Percentage of Gross Domestic Product
50
45
40
35
Percent
30
All Other Health Care
25
20
15
Medicaid
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Source:
Congressional
Budget Office,
2008
Medicare
5
0
2007
2012
2017
2022
2027
2032
2037
2042
2047
2052
2057
2062
2067
2072
2077
2082
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Health Reform Elements
Major Policy Area
Critical Value Policies
Coverage expansion and
Financing
1. Align public and private policies
2. Connector or Exchange promoting value
Benefits
3. Assure core benefits promote affordable
“right care”
System Reforms
4. Full measures and public reporting
(including release Medicare data)
5. Promote wellness
6. Consumer and provider incentives for
shared decisions
7. Payment reform – Change payments AND
the decision process
Infrastructure
8. Patient-centered comparative
effectiveness
9. HIT that promotes better care
10. Foster innovation
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Comparative Effectiveness Research: Different
perspectives on what it is…
“Comparative-effectiveness analysis evaluates the relative value of drugs, devices,
diagnostic and surgical procedures, diagnostic tests, and medical services.” MedPAC
“Assessing the comparative effectiveness of health care treatments and strategies,
through efforts that: (1) conduct, support, or synthesize research that compares the
clinical outcomes, effectiveness, and appropriateness of items, services, and
procedures that are used to prevent, diagnose, or treat diseases, disorders, and other
health conditions.” ARRA 2009
“Comparative effectiveness is simply a rigorous evaluation of the impact of different
options that are available for treating a given medical condition for a particular set of
patients.” Congressional Budget Office
• Head-to-head comparisons of drugs
• Drugs vs. surgical procedures
• Drugs vs. surgical procedures vs. public health interventions
• Physician outcomes vs. physician outcomes
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Current CER Activity
•
American Recovery and Reinvestment Act of 2009 funded $1.1 billion
– $400 million NIH, $300 million AHRQ, $400 million HHS
– Federal coordinating council to advise on priorities
– IOM to produce priorities by June 30
• Triggered significant manufacturer pushback
• Encourages the development and use of clinical registries, clinical networks, and
other forms of electronic health data
• Role of costs/cost-effectiveness left unclear
•
Congressional Proposals (e.g., Senate Finance Committee Options Paper)
– Fund existing HHS entities through annual appropriations
– Establish private, non-profit corporation
• Fund through annual appropriations or by mix of public and private
– Coming this Summer -- comparative effectiveness legislation 2.0
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Doing Comparative Effectiveness Right:
Big Money, Big Interests and Bad Messaging
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Comparative Effectiveness Research: Big
Issues
•
•
•
•
•
Individualized Care vs. One-size Fits All
Ensuring Disparities Are Not Exacerbated (or ignored)
Common Conditions vs. Rare Diseases
Inclusion of Cost and/or Cost-Effectiveness
Paying for Unproven Care vs. “Rationing” or Denial of
Coverage
• Rewarding What Works vs. Stifling of Innovation
• Rigor of Scientific Evidence
• Who Decides – what to research; what to do with the
results
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Consumer-Purchaser Principles on Doing Comparative
Effectiveness Right: Discussion Draft – May 5, 2009
1.
Public investment: comparative effectiveness research is an important public good
that warrants substantial and ongoing public investment
2.
Independence and governance: oversight of CER should be as removed as possible
from political influence, with processes assuring patient, clinician, purchaser and other
input.
3.
Total transparency: determination of what to research and the research itself must be
totally transparent
4.
Effective coordination: there should be coordination across public and private funders
of CER to assure that the right mix of questions are being asked, the right mix of
methodologies are being used, and resources are being used efficiently
5.
Prioritization: CER research should be prioritized on those areas with highest potential
to assure patients get the right care (e.g., variation, overall poor performance, etc)
6.
Scope: CER should assess multiple treatment types and interventions
7.
Results: CER should generate results in areas that matter – outcomes, functional
status, patient experience, utilization, expense of all care delivered based on treatment
options and differences across populations
8.
Dissemination: results of CER should be disseminated broadly for use by patients,
clinicians, researchers and purchasers (and there should not be restrictions on use)
9.
Health IT: health information infrastructure should be funded and aligned with CER
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About the Disclosure Project
The Consumer-Purchaser Disclosure Project is an initiative that is improving health
care quality and affordability by advancing public reporting of provider performance
information so it can be used for improvement, consumer choice, and as part of
payment reform. The Project is a collaboration of leading national and local
employer, consumer, and labor organizations whose shared vision is for Americans
to be able to select hospitals, physicians, and treatments based on nationally
standardized measures for clinical quality, consumer experience, equity, and
efficiency. The Project is funded by the Robert Wood Johnson Foundation along
with support from participating organizations.
Previous Discussion Forums are available at: http://healthcaredisclosure.org/activities/forums/
For More Information Contact:
Jennifer Eames, MPH
Associate Director
415-281-8660
[email protected]
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