National Academy For State Health Policy Learning Collaborative From Engagement to Evidence: Using PCOR & CER to Inform State Policymaking July Group W ebinar State Leaders in Evidence-based Policymaking July 13, 2016 3-4pm Eastern Call-in: 866-740-1260 Enter access code: 8746524 his wo rk was suppo rte d thro ugh a Patie nt-Ce nte re d Outc o me s � Re se arc h I T nstitute (PCORI ) Pro gram Award 1 (E A-2159-CHPD).
Agenda Darren Coffman Oregon Health Evidence Review 3:00 – 3:20pm Commission (HERC) Dan Lessler and Gary Franklin Washington State Agency Medical 3:20-3:40pm Director’s Group (AMDG) Group discussion / Q&A 3:40-4:00pm 2
���������������� ������������������������������������������ ������������������������������������� � ������������������������������������� �������������� � Darren Coffman Director, Health Evidence Review Commission 3
Commission History • Oregon Health Plan Legislation passed in 1989 (SB 27) • Health Services Commission (1989-2011) • Health Evidence Review Commission (2012-Present) • 13 Governor-appointed, Senate-confirmed Members – 5 Physicians ̶ Complimentary & alternative – Dentist medicine – Public health nurse ̶ Retail pharmacist – 2 consumers ̶ Insurance industry – Behavioral health • Volunteers, reimbursed for travel expenses � 4
Medicaid Expansion • Commission established to create Prioritized List, funded by 50% GF/50% FF, shoestring budget • “Not subject to alteration by any other state agency” • Legislature draws funding line subject to CMS approval – Expanded coverage to 100% FPL in 1994 • List represents “health services ranked by priority, from the most important to the least important, representing the comparative benefits of each service” o “Commission shall actively solicit public involvement through a public meeting process” o “Consider cost effectiveness as well as clinical effectiveness � using peer-reviewed medical literature ” 5
Assumptions of the List • Every person is entitled to a diagnosis – Diagnostic office visit(s) – Imaging/lab – Biopsies • Each covered condition includes – Prescription drugs – DME and supplies – Other ancillary services • Services Recommended for Non-Coverage do not appear on list – Excluded in Department of Medical Assistance Programs administrative rules (e.g., infertility treatment) – Cosmetic services – Experimental treatments – Not effective for any condition 6 6
Sample Prioritized List Line Condition/Treatment Line number descriptions Reference to guideline (funding line is (plain English notes 476 for this list) approximations) Line: 183 Condition: ACUTE LEUKEMIA, MYELODYSPLASTIC SYNDROME (See Guideline Notes 7,11,12,14) Treatment: BONE MARROW TRANSPLANT ICD-10: C88.8,C90.10-C90.12,C91.00-C91.02,C95.00-C95.02,D46.0-D46.1,D46.20-D46.9,D47.1,D47.3, D61.810,Z48.290,Z52.000-Z52.098,Z52.3 CPT: 36680,38204-38215,38230-38243,64505-64530,86828-86835,98966-98969,99051,99060,99070, 99078,99184,99201-99239,99281-99285,99291-99404,99408-99416,99429-99449,99468-99480, 99487-99498,99605-99607 HCPCS: G0396,G0397,G0406-G0408,G0425-G0427,G0463,G0466,G0467,S2142,S2150,S9537 If the diagnosis and the procedure appear on the same line, the service is covered said to “pair” (though it may be subject to a guideline note or coding speci fi cation) If the line number where it “pairs” is above the funding line, it’s covered. 7
Examples of Rankings in 2016 Funded Lines: Unfunded Lines: 26 Schizophrenia 479 Chronic Otitis Media 51 Appendicitis 516 Esophagitis and GERD 143 Glaucoma (long-term medical therapy) 195 Breast Cancer 527 Uncomplicated Hernia 348 Dental Caries (Fillings) 565 Transplant for Liver Cancer 360 Closed Fracture of 609 Sleep Disorders w/o Apnea Extremities 617 Common Cold 373 Strep Throat 415 Migraine Headaches 8
Use of Prioritized List by CCOs • CCOs (contracted plans) consistently report they: – Use the Prioritized List to deny coverage for treatments with little or no clinical benefit – Use the clinical practice guidelines included in List to manage services by according to disease severity, step therapy, etc. when benefits are being limited to specific populations – Save administratively from having to do their own evidence review, which would be added costs in order to set their coverage policies • The List provides for more statewide consistency in the provision of benefits across the CCOs & FFS program 9
Public Engagement • All meetings public • Four statewide forums held at times of critical input • Topic suggestions may be given directly to staff • Allow unsolicited brief presentations (with notice) • Ad hoc verbal comments are generally very limited • 4000 member listserv • Expanded outreach during biennial review of List – Interim modifications twice per year • Monthly updates/feedback at meetings of medical directors of contracted plans (CCOs) 10
Evidence-Based Process • Decisions historically based on expert opinion. Evidence-based medicine has shifted coverage decisions to rely on systematic reviews and quality trials where possible. – Supporting evidence needed to place new services on list – Evidence of harm or ineffectiveness can be used to removed existing services from list • Cost-effectiveness considered where available when outcomes are similar between treatments • Incorporate recommendations of coverage guidances 11 11
Coverage Guidances • In-depth review of more challenging, emerging clinical issues faced by CCO medical directors • Recommendations in the guidances are intended for both private and public payers and purchasers – 46 coverage guidances in last two years have resulted in 42 updates to Prioritized List for OHP – New work to identify how decision support tools can be used to guide providers/patients in encouraging most clinically effective/cost-effective care 12
HERC Subcommittee Structure HERC ���������������� �������� � ������� � �������� � EbGS VbBS HTAS Evidence-based Value-based Health Technology �������� � �������� � Guidelines Benefits Assessment �������� � �������� � Subcommittee Subcommittee Subcommittee 13
Coverage Guidance Process Overview Topic Topic Selection Identification Report Monitoring Development Review and Approval 14
Report Development • 7-day comment period on scope statement • Ad hoc expert appointed if needed • Review staff initial draft report EbGS/HTAS • Can modify or request additional research, review then post for comment • 30 days, posted on HERC website and announced through HERC e-gov delivery service • Maximum of 1000 words plus citations per Public comment commenter period 15
Report Development (cont’d) • Public comment disposition document responds to each comment received • HTAS/EbGS may revise draft recommendations based on public comments, and may post for additional 21-day comment period Review public • Approves final draft comment • Reviews coverage guidance, and may make changes to Prioritized List which guides coverage for the Oregon Health Plan Review by VbBS • 30-day public notice • HTAS/EbGS approved draft posted 14 days prior to meeting • May modify report and associated prioritization changes prior to Review by approval or request further work HERC 16
Coverage Guidance Example 17
GRADE-Informed Framework (Additional outcomes omitted for brevity) 18
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EVIDENCE-BASED POLICY IN WA STATE NASHP PCOR/CER LEARNING COLLABORATIVE JULY 13, 2016 Gary M Franklin , MD, MPH Medical Director WA Dept Labor and Industries Dan Lessler , MD, MHA Chief Medical Officer WA Health Care Authority Co-Chairs, WA Agency Medical Directors Group (AMDG) 20
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