Value Tools in Managed Care Decision Making: Current Hurdles and Future Opportunities.

BACKGROUND: Organizations such as the National Comprehensive Cancer Network, American Society of Clinical Oncology, Institute for Clinical and Economic Review, and Memorial Sloan Kettering have created distinct tools to help different stakeholders assess the value of oncology treatments. However, the oncology value tools were not necessarily created for payers, and it is unclear whether payers are using these tools as part of their drug management process. OBJECTIVE: To understand what value tools payers are using in oncology management and what benefits and shortcomings the tools may have from the payer perspective. METHODS: A survey targeting drug coverage decision makers at health plans was conducted in August 2016. Respondents attesting to using 2 or more value tools in drug management were eligible for an additional in-depth interview to understand the respondents' perceived benefits and shortcomings of current value tools. Respondents also were asked to describe desired attributes of a hypothetical payer-centric value tool. RESULTS: A total of 28 respondents representing approximately 160 million commercially insured medical lives completed the survey. Twenty respondents (71%) reported using at least 1 value tool in their drug management process. Twelve respondents (43%) used at least 2 tools, and 4 respondents (14%) used at least 3 tools. A total of 6 respondents were selected for in-depth interviews. Interviewees praised value tools for advancing the discussion on drug value and incorporating clinical evidence. However, interviewees felt available value tools varied on providing firm recommendations and relevant price benchmarks. Respondents most commonly recommended the following attributes of a proposed payer-centric value framework: taking a firm position on product value; product comparisons in lieu of comparative clinical trials; web-based tool access; and tool updates at least quarterly. Interview respondents also expressed some support for allowing manipulation of inputs and inclusion of quality-of-life and patient-reported outcome data. CONCLUSIONS: Although nearly half of payers surveyed use 2 or more value tools in the drug management process, payers identified a number of areas where the tools could be revised to increase their utility to payers. DISCLOSURES: No outside funding or assistance of any kind was used for this research or in manuscript preparation. Schafer and Galante are employed by Precision for Value, a payer ad marketing agency that works exclusively with life science companies. Shafrin is employed by Precision Health Economics, a consulting company to insurance and life science industries. Shafer, along with Galante and Shafrin, contributed to study design, data collection, and manuscript preparation. The authors contributed equally to data analysis and interpretation and manuscript revision.

Opportunities and challenges for measuring cost, quality, and clinical effectiveness in health care.

Empirical studies of health care cost, productivity, and output have focused primarily on intermediate goods and services. Consumers are ultimately interested in final goods such as improved health or health-related quality of life, but health services research continues to address whether health services financing and delivery are structured in ways to maximize production of intermediate goods, regardless of the link between these services and final outcomes. Increasing rates of growth of health care cost and dissatisfaction with the quality of U.S. health care force us to reexamine how productivity and cost are analyzed so that research properly informs policy and practice. The authors examine recent changes in the U.S. health care sector that suggest the need to revise how health services research approaches analyses of cost, production, and output; consider alternative notions of final goods; and review the availability and quality of data necessary to conduct this research.

The Undergraduate Medical Education for the 21st Century (UME-21) project: the Federal Government perspective.

The Undergraduate Medical Education for the 21st Century (UME-21) project was implemented by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration (HRSA) to encourage medical schools to collaborate with managed care organizations and others. The purpose of the collaboration was to ensure that medical students are prepared to provide quality patient care and manage that care in an integrated health care system in which the cost of care and use of empirically justified care are important elements. The UME-21 project represents a continuation of HRSA's interest in the managed care arena. The UME-21 project involved the collaboration of eight partner schools and 10 associate partner schools, together with 50 external partners, to develop innovative curricula that integrated UME-21 content from nine special areas as learning objectives. This project demonstrated that concerted efforts by the leadership in medical education can bring about innovative change in medical school curricula. It ís also demonstrated that faculty of the three primary care disciplines of family medicine, general internal medicine, and general pediatrics were able to cooperate to accomplish such change by working together to allocate clerkship time and content. An important lesson learned in this project was that significant innovations in medical school curricula could be accomplished with a broadbased commitment and involvement of both faculties across the three primary care disciplines and top administrative officials of the medical school. It is uncertain, however, if the innovations achieved will produce further changes or if those changes achieved can be sustained without continued funding.

Getting along or going along? Health plan-provider contract showdowns subside.

Although contract negotiations between health plans and providers have remained tense during the past two years, overt impasses have declined, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. The balance of power stabilized during the period, with providers, particularly hospitals, solidifying their dominant negotiating positions and securing concessions from plans in the form of significant payment rate increases and more favorable contract terms. Many plans have recognized and accepted their weaker position relative to providers, suggesting the recent lull indicates plans have found it in their interests to accommodate provider demands for higher payments, rather than resist them and possibly trigger a contract showdown. Though no immediate change is likely in this environment, there are emerging forces that could swing the power pendulum back toward plans.

[Family health centers in Israel: to change or not to be].

As reported in this issue, the Ministry of Health Family Health Centers (FHC) in Israel is not fulfilling some of the requirements of the Ministry of Health. For example, hemoglobin levels are not checked in all of the babies and at least 31% of the babies do not receive supplemental iron. Universal neonatal screening for hearing loss by objective methods is not conducted nor recommended by the Ministry of Health, as advised by pediatric professional organizations, while screening for hearing loss is conducted in the second half of the first year by a method which is not currently recommended. FHC physicians conduct initial screening for suspected developmental dysplasia for only some of the children, while too many children go directly to the orthopedic specialist. Previous studies have shown that only 20% of Jewish women residing in larger townships in Israel use the FHC for prenatal care. Based on all the above the government policy makers are facing hard decisions regarding FHC services. One option is to transfer all services to the health maintenance organizations. A second option is to maintain the FHC with the following modifications: 1) revise and update the health management guidelines to meet universal recommendations; 2) improve compliance to guidelines; 3) improve outreach and acceptance by the public of the services of the FHC.

Infants with bilirubin levels of 30 mg/dL or more in a large managed care organization.

OBJECTIVE: To describe the incidence, etiology, treatment, and outcome of newborns with total serum bilirubin (TSB) levels >or=30 mg/dL (513 micro mol/L). DESIGN: Population-based case series. SETTING: Eleven Northern California Kaiser Permanente Medical Care Program hospitals and 1 affiliated hospital. PATIENTS: Eleven infants with TSB levels of >or=30 mg/dL in the first 30 days after birth, identified using computer databases from a cohort of 111,009 infants born 1995-1998. OUTCOME MEASURES: Clinical data from the birth hospitalization, rehospitalization, and outpatient visits in all infants; psychometric testing at age 5 (N = 3), neurologic examinations by child neurologists at age 5 (N = 3), or primary care providers (N = 7; mean age: 2.2 years); Parent Evaluation of Developmental Status (N = 8; mean age: 4.2 years). RESULTS: Maximum TSB levels of the 11 infants ranged from 30.7 to 45.5 mg/dL (525 micro mol/L to 778 micro mol/L; mean: 34.9 mg/dL [597 micro mol/L]). Four were born at 35 to 36 weeks gestation, and 7 were exclusively breastfed. Two had apparent isoimmunization; the etiology for the other 9 remained obscure, although only 4 were tested for glucose-6-phosphate dehydrogenase deficiency and 1 was bacteremic. None had acute neurologic symptoms. All received phototherapy and 5 received exchange transfusions. One infant died of sudden infant death syndrome; there was no kernicterus at autopsy. Two were lost to follow-up but were neurologically normal when last seen for checkups at 18 and 43 months. One child was receiving speech therapy at age 3. There were no significant parental concerns or abnormalities in the other children. CONCLUSIONS: In this setting, TSB levels >or=30 mg/dL were rare and generally unaccompanied by acute symptoms. Although we did not observe serious neurodevelopmental sequelae in this small sample, additional studies are required to quantify the known, significant risk of kernicterus in infants with very high TSB levels.

Something old, something new: recent developments in hospital-physician relationships.

OBJECTIVE: To describe recent developments in hospital-physician relationships in 12 metropolitan areas. METHODS: We analyze qualitative data from a third round of biannual site visit interviews conducted in 12 randomly selected metropolitan areas from 1996 to 2001. The study interviewed 895 respondents during the third round of site visits, conducted in 2000 and 2001. PRINCIPAL FINDINGS: As HMO enrollment and capitation contracting has failed to grow in local markets, hospital executives have returned to a strategic focus on improving relationships with specialists in pursuit of fee-for-service revenue. Yet, 65 percent of hospitals interviewed in 2000 and 2001 continued to own primary care physician practices, with ownership more prevalent in highly concentrated hospital markets. A majority (55 percent) of hospitals have decreased the size of these practices in the past two years. CONCLUSIONS: Interest in forming integrated delivery systems has waned. The potential for quality improvement through these organizations systems--by emphasizing primary care and coordinating hospital and physician services--has not been realized. The new emphasis on hospital-specialist partnerships may improve the financial status of hospitals and participating specialists in local markets, and may improve quality of care in selected service areas, but it may also increase health care costs incurred by employers and consumers.

Strategic health system development and managed care delivery.

For the past quarter century major hospitals and physician groups have actively developed competitive health systems. Their compelling motivation has been fueled by the onslaught of managed care. Successful initiatives have been driven by mutual strategic system planning, effective management, and enhanced quality of care.

The search for value in health care: a review of the National Committee for Quality Assurance efforts.

Large employers formed the National Committee for Quality Assurance (NCQA) to ensure value to healthcare purchasers. Value in healthcare is a function of quality divided by costs. Through NCQA's role as an accrediting agency for healthcare organizations and the development of performance measures, Health Plan Employer Data and Information Set (HEDIS), gains toward defining the value of health services have materialized. An analysis of the impact of HEDIS data collection on physician practices and the influence of HEDIS data on employer, employee, and governmental health plan selections is examined. This study consisted of a general review, from 1993 to 2001, of HealthStar databases, PubMed databases, and the NCQA website. NCQA accreditation is accepted as an important industry milestone for health plans, credentials verification organizations, and physician organizations. The data for HEDIS is collected from health plan administrative data repositories, whereas health plan members' clinical data may be collected by chart abstraction in physician offices. Data collection in physician offices consumes administrative resources from physician practices and health plans. As commercial and governmental insurers move toward greater adoption of HEDIS measures, complex implications are created for physician practices and vulnerable populations. There are lingering questions regarding the improvements in quality of care for medically underserved populations and physician practice costs attributable to HEDIS.

Medicaid and indigent care issue brief: Medicaid: provider reimbursement: year end report-2002.

Medicaid provider reimbursement rates have been a hot topic for the last several years. Twenty-eight states including California, Hawaii, Indiana, Maryland, Mississippi, New York, and Wisconsin addressed the issue in the 2000 legislative session while 30 states enacted legislation dealing with provider reimbursement in 2001.

Forecasting the health care future. Futurescan 2001 and its implications for health care marketing.

In his new book, futurist Russell C. Coile Jr. presents predictions about seven aspects of health care for the next five years. Aided by a panel of health care experts, he analyzes likely developments in health care consumerism, technology, managed care, and other areas that raise a number of issues for health care marketers. Even if only a few of these predictions come true, marketers will be forced to rethink some of their techniques to adapt to this rapidly changing environment.

A regional survey of health insurance coverage for complementary and alternative medicine: current status and future ramifications.

OBJECTIVE: The purpose of this survey is to evaluate the extent of health insurance coverage for complementary and alternative medicine (CAM) within one region in the United States, a study prompted by the increased utilization of CAM. DESIGN: Prospective telephone interview of health insurance representatives. LOCATION: A contiguous three-state area (New York, New Jersey, and Connecticut) in the North-east. RESULTS: Almost all of the insurers surveyed cover chiropractic services. Less than half of the insurers reimburse acupuncture, usually for chronic pain management. Coverage for massage therapy is minimal and usually associated with physical therapy or chiropractic treatment. Other CAM services receive negligible coverage. CONCLUSIONS: Current health insurance coverage of CAM is limited essentially to chiropractic medicine, acupuncture and massage therapy. Coverage of CAM is made confusing by different policies, practitioner requirements, and health plans within each carrier.

The next iteration of managed care? Panel discussion.

What did our five panelists predict for the next iteration of managed care? What do they see happening now? What will the health care industry look like in ten years? Employers will shift an increasing share of rising medical and prescription drug costs to consumers through higher co-pays and defined contributions. Some providers may market their services to attract these consumers. Tightly managed HMOs will provide access to lower-income consumers. So for, e-health is helping managed care organizations cut administrative costs, but not medical expenses. Genetic testing and therapies will not be commercially available for ten to 15 years. Based on demographic trends and labor shortages, demand is likely to exceed the capacity of the health care system within the next three decades. Our five experts caution that managed care is as unpredictable and chaotic as ever, but they do their best to tell you how they think it'll all play out in the near term.

The next wave of change for psychology and mental health services in the health care revolution.

Recent national changes in the de facto system of health and mental health care are described. Although the percentage of people without health insurance (always or sometimes) has not decreased, the organization of insured care has changed dramatically. Of the insured population, 75% are under some form of managed care. For 88% of the managed care population, mental health care has not been integrated with health care: the so-called carve-out. The author argues that system integration (carve-ins), for a variety of reasons, will begin soon and will occur very rapidly. A tilt toward carve-ins will have substantial impact on psychologists' training, service delivery, and research.