Findings Related to Assessing Value for Private US Health Plans
ABSTRACT
Objective: To assess US private payers’ perceptions of medical product value and needs for evidence evaluation, as well as whether formulary drug placement decisions of several US health plans refl ect value according to published cost-effectiveness evidence.
Study Design: A qualitative survey focused on evidence evaluation for medical products with 15 US payer–related organizations. A quantitative, pharmaceutical-focused costeffectiveness database analysis evaluated 9 US payers.
Methods: Qualitative telephone interviews were used to collect data from payers. A cost-utility analysis (CUA) evaluated formulary policies.
Results: The qualitative findings suggest that health plan officials are most interested in clinical safety, efficacy, and effectiveness evidence. Payers’ demands are increasing for more clinical utility and clinical performance studies providing comparative information for medical products. For pharmaceuticals, payers rely on phase 3 randomized controlled trials as their primary evidence source for establishing coverage and reimbursement policies. For devices, diagnostic tests, and other products, payers must rely on more limited clinical and economic evidence. The CUA evaluation revealed numerous instances of drugs with favorable published CUAs and nonfavorable formulary positioning, as well as unfavorable published CUAs that received favorable formulary placement.
Conclusions: US payers are not clearly and consistently defining the concept of medical product value. Policies aimed at improving evidence-based decisions and aligning incentives include comparative effectiveness studies, consumer-directed initiatives, and physician pay-for-performance programs. Discrepancies between published pharmaceutical cost-effectiveness value estimates and product positioning suggest that health plans do not suffi ciently incorporate value evidence into their formulary policies.
(Am J Pharm Benefits. 2010;2(3):219-227)
Objective: To assess US private payers’ perceptions of medical product value and needs for evidence evaluation, as well as whether formulary drug placement decisions of several US health plans refl ect value according to published cost-effectiveness evidence.
Study Design: A qualitative survey focused on evidence evaluation for medical products with 15 US payer–related organizations. A quantitative, pharmaceutical-focused costeffectiveness database analysis evaluated 9 US payers.
Methods: Qualitative telephone interviews were used to collect data from payers. A cost-utility analysis (CUA) evaluated formulary policies.
Results: The qualitative findings suggest that health plan officials are most interested in clinical safety, efficacy, and effectiveness evidence. Payers’ demands are increasing for more clinical utility and clinical performance studies providing comparative information for medical products. For pharmaceuticals, payers rely on phase 3 randomized controlled trials as their primary evidence source for establishing coverage and reimbursement policies. For devices, diagnostic tests, and other products, payers must rely on more limited clinical and economic evidence. The CUA evaluation revealed numerous instances of drugs with favorable published CUAs and nonfavorable formulary positioning, as well as unfavorable published CUAs that received favorable formulary placement.
Conclusions: US payers are not clearly and consistently defining the concept of medical product value. Policies aimed at improving evidence-based decisions and aligning incentives include comparative effectiveness studies, consumer-directed initiatives, and physician pay-for-performance programs. Discrepancies between published pharmaceutical cost-effectiveness value estimates and product positioning suggest that health plans do not suffi ciently incorporate value evidence into their formulary policies.
(Am J Pharm Benefits. 2010;2(3):219-227)
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