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8 Structuring the Incentives for Change
Pages 289-314

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From page 289...
... These perspectives engage only a sampling of the sorts of incentives to development of a learning healthcare system, but they represent important focal points for stakeholder alignment. Alan Rosenberg of WellPoint offers a perspective from the health insurers industry on opportunities for encouraging both evidence development and application.
From page 290...
... New models for product development such as evidence-based drug development will accelerate the creation of a learning healthcare system by making clear breaks with outdated approaches. For example, embedding the creation of effectiveness data into the process of drug development or developing a continuous process of evidence creation in partnership with the regulators and payers might provide sufficient financial incentives to drive change.
From page 291...
... This paper also discusses two initiatives -- data integration for electronic health records (EHRs) and consumer-focused initiatives -- along with the methods used, the importance of collaboration, and some of the hurdles from the private insurer perspective in achieving these goals.
From page 292...
... Through analysis of this dataset, and by other insurers as well, post-market surveillance can be undertaken. WellPoint, with its affiliate HealthCore, did submit information to the Food and Drug Administration (FDA)
From page 293...
... However, litigation continues to be a significant mitigation in the insurers' ability to fully apply evidence-based medical necessity benefit determinations. One significant initiative at WellPoint to better support the diffusion of claims information into practice is data integration for electronic health records.
From page 294...
... . Healthcare researchers generally agree that this will increase the availability of useful clinical information in claim databases.
From page 295...
... A national standard for the operational architecture for electronic health records is an essential first step. Many facilities, clinics, and offices are hesitant to enter into EHRs, fearful that standards may change and expensive systems become obsolete.
From page 296...
... workshop requires collecting data in ways that may not have the same scientific base as the typical clinical trial methodological sciences. Healthcare research has a fairly well thought out and well designed research methodology, but the research methodology for collecting, analyzing, and utilizing data in other manners -- data from claims databases, registries, emerging death data -- is much less clear.
From page 297...
... 2 STRUCTURING THE INCENTIVES FOR CHANGE the recall. That information is not available to payers.
From page 298...
... • CSP research conducted may include a broader range of studies than randomized clinical trials to include observational research. However, all studies must conform to the standards that will be developed by the Clinical Research Policy.
From page 299...
... 2 STRUCTURING THE INCENTIVES FOR CHANGE In rare instances, for some items or services, CMS may determine that the evidence is very preliminary and not reasonable and necessary for Medicare coverage, but, if the following criteria are met, CSP might be appropriate: • The evidence includes assurance of basic safety; • The item or service has a high potential to provide significant ben efit to Medicare beneficiaries; and • There are significant barriers to conducting clinical trials. The implantable cardioverter defibrillator (ICD)
From page 300...
... Rosenkrans, Jr., Ph.D., Catherine Bonuccelli, M.D., and Nancy Featherstone, M.B.A. AstraZeneca Pharmaceuticals From the point of view of a pharmaceutical firm, the opportunities and challenges in moving toward a learning healthcare system fall into three categories: appropriate evidence creation, appropriate use of evidence, and evidence-based drug development.
From page 301...
... 0 STRUCTURING THE INCENTIVES FOR CHANGE Health Technology Assessment (HTA) guidelines reach so far beyond that of the Academy of Managed Care Pharmacy (AMCP)
From page 302...
... Adoption of computerized decision-support systems paired with electronic health records has been shown to improve patient compliance with clinical guidelines. Personal health records may provide a vehicle for patients to own -- and understand -- their own health status and data.
From page 303...
... 0 STRUCTURING THE INCENTIVES FOR CHANGE service. A payer is often seen as a trusted authority on evidence assessment and thus able to influence physicians' beliefs about best clinical practices.
From page 304...
... Over the last six years, the average cost of health insurance for a family of four Americans has jumped 87 percent, a larger increase than any other sector of our economy (Kaiser Family Foundation 2006)
From page 305...
... 0 STRUCTURING THE INCENTIVES FOR CHANGE increase and the accompanying shift of costs to employees ate up much of the average 3.8 percent rise in Americans' wages (Kaiser Family Foundation 2006)
From page 306...
... 0 THE LEARNING HEALTHCARE SYSTEM ment and behavioral modification. As a population moves further toward high risk and active illness, we must give people the appropriate care and support to keep them as healthy as possible.
From page 307...
... 0 STRUCTURING THE INCENTIVES FOR CHANGE TABLE 8-1 HEDIS Effectiveness of Care Measures • Prevention • Chronic Care Conditions – Cancer Screening – Hypertension • Breast cancer – Diabetes (6) • Cervical cancer – Cardiovascular Disease • Colon cancer • Cholesterol test & results – Immunizations (Children & Adolescents)
From page 308...
... We lack clinical trial data for the elderly. We do not know about the comparative effectiveness of many treat ments so that we cannot evaluate how treatment "A" compares to treatments "B" or "C" in terms of risks, outcomes, and costs.
From page 309...
... 0 STRUCTURING THE INCENTIVES FOR CHANGE needed, but randomized clinical trials rarely address more complex patients. • The absence of care guidelines.
From page 310...
... The advent of electronic health records will help decrease the burden and expense of data collection -- but only if we get the right kind of EHRs. The current generation of EHRs leaves much to be desired in terms of their usefulness to improve quality.
From page 311...
... identify priority areas for new evidence development; and (3) consider ways to move beyond clinical trials in an era when much more real-time information can be gleaned from practice and used to study what works.
From page 312...
... 2 THE LEARNING HEALTHCARE SYSTEM BOX 8-2 Policy Enablers Needed: • Payment reform • Regulatory reform • Liability reform • Patient Activation services. It is time for a new generation of payment reform that utilizes bundled payments with strong incentives for efficient delivery of highquality care.
From page 313...
... 2004. Consumer-directed health plans and the RAND Health Insurance Experi ment.


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