Both prioritization and review production should be centralized
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The document discusses the need for a comparative effectiveness center to provide better healthcare information and improve outcomes. It notes key considerations in establishing such a center, including focusing on medical conditions rather than specific interventions, using various data sources, governance structure, funding options, priorities, and how cost-effectiveness can be incorporated without undermining the center's objectives. The center would assess what treatments work best for which patients but not determine coverage, reimbursement or practice guidelines.
Both prioritization and review production should be centralized
- 1. Gail R. Wilensky Project HOPE July 11, 2008 Better Information for Better Decisions
- 2. First Need the Information – Comparative Effectiveness - Basic Building Block… “ What works when, for whom, provided by…” Recognition that “technology” is rarely always effective or never effective Information on… also…
- 3. CCE Needs the Right Focus Better information to “ spend smarter ” and improve outcomes ♦ Focus on conditions rather than i nterventions/therapeutics ; procedures , not just Rx and devices ♦ Use what is known more effectively; invest in what is not yet known ; Dynamic Process…
- 4. Comparative Effectiveness Should Include Data from Many Sources ♦ “ Gold Standard” - - double-blinded RCT ♦ “ Real World” RCT; PACE ♦ Epidemiological studies; medical record analyses ♦ Administrative data Need to understand: All data have limitations
- 5. Different Views on Placing a CCE Center ♦ In HHS? Separate agency; FFRDC, AHRQ ♦ Free standing agency in Exec. Branch like FTC, FRB ♦ Quasi-Gov’t IOM/NRC “ Close to Gov’t…But not too close”
- 6. Advantages/Disadvantages Trade-offs with all placements ♦ If use existing bureaucracy, don’t need new one ♦ Vulnerability of existing institutions to political pressures ♦ Credibility – stronger inside or outside gov’t? +/- ♦ Accountability – harder the further from gov’t If start at AHRQ, reassess in 2-3 years
- 7. Governance Issues are also Important ♦ Governing body needs to reflect major stakeholders -- part of center or freestanding ♦ Appointments by Executive branch with confirmation by Senate; staggered terms ♦ Specialized scientific advisory boards, created for specific issues ♦ Should include both intramural and extramural activities
- 8. Funding of Center ♦ Preferred Strategy: ♦ Realistic Strategy: direct appropriation information is a “ Public Good ” direct appropriations contribution from Medicare trust fund Small “user fee” on all privately insured Problem with employers . . .
- 9. What a Comparative Effectiveness Center is NOT ♦ Not providing a new coverage requirement used for practice decisions/ reimbursement ♦ Not a decision-making center ♦ Not a cost-effectiveness center ♦ Not a monopoly continuing roles for BCBS Center, Cochrane, OHSU
- 10. Setting Priorities for CCE Center Starting Point: High cost medical conditions with lots of variation in treatment Proxy: Conditions reflecting highest cost DRG’s with substantial geographic variation Also: Allow private funding of CCE assessments, subject to guidelines/with auditable results
- 11. How to Bring in Cost-Effectiveness ♦ Fund cost-effectiveness studies with same funding stream as CCE ♦ Strong preference to keeping activities separate -- at AHRQ or CMS or wherever ♦ CMS needs new authority to use C/E -- reimbursement vs. coverage ♦ Private payers can fund additional C/E studies -- universities; free standing centers
- 12. “ Spending Smarter” Also Means Better Incentives ♦ Need to realign financial incentives ♦ Reward institutions/clinicians who provide high quality/efficiently produced care ♦ Reward healthy lifestyles by consumers ♦ Use “Value-based” insurance in private sector
- 13. ♦ Some interest across the political spectrum ♦ Physician groups just beginning to “declare themselves ♦ Industry support is mixed – Big pharma ok as long as transparent process, minimal extra delay Small pharma/biotech worried about delays; Device companies nervous about small incremental improvements Lots of Interest