The New England Comparative Effectiveness Public Advisory Council

1. The New England
Comparative Effectiveness Public
Advisory Council
Translating federal HTA reviews to
support payer policy decisions

2. Barriers to effective use of
HTA reviews
• Lack of cost information
• Not timed to decision-making
• Content
– Too long and diffuse, too much focus on
uncertainty, no straightforward guidance
• Not persuasive with local clinical experts
– Need to integrate evidence review with local views
• Lack of public legitimacy
– Difficult to make negative judgments on evidence
given perceived conflict of interest
2

3. New England CEPAC:
Structure, Content, and Process
 Structure
– Independent from state and private payers
– 19 members (minimum two per state)
– 2:1 ratio of practicing clinicians with evidence review experience
and public health policy experts
– Ex-officio representation of public and private payers
 Supplementary Content
– Recently published studies
– State-specific data
• Prevalence, utilization patterns
– Comparative value analysis: costs, budget impact scenarios, and
cost-effectiveness analysis
3

4. CEPAC Process
 Process
– Receive adapted AHRQ review
– Discussion with regional clinical experts
– Public deliberation, voting
– Policy roundtable to discuss applications of CEPAC
findings
4

5. CEPAC Report
 Voting
– Is the evidence adequate to demonstrate that drug A is
equivalent or superior to drug B for patients with condition
X?
• If yes, is drug A equivalent or superior?
• If no, what are the deficiencies in the evidence?
– *Based on reimbursement levels provided with this report,
would you judge the comparative value of drug A to be
• High value
• Reasonable value
• Low value compared
5

6. CEPAC Report
 Policy recommendations
– Actions desired by specialty societies, hospitals, other
stakeholders
– Comments on coverage options, e.g. prior authorization or
CED
– Future research recommendations

7. Topics
 Catheter ablation for atrial fibrillation
 Treatment-resistant depression
 Attention Deficit Hyperactivity Disorder (ADHD)
7

8. Treatment Resistant Depression
– Transcranial Magnetic Stimulation (TMS)
• Not covered by any insurers
– Electroconvulsive Shock Therapy (ECT)
• Covered by all insurers
– Vagus Nerve Stimulation (VNS)
• Not covered by any insurers

9. Key Votes
 10 to 5 that evidence was adequate to demonstrate
equivalent or superior clinical effectiveness for TMS
compared to usual care
– 5 voted “superior”; 5 voted “equivalent”
– Comparative value: 6 “reasonable” value; 4 “low” value
 9 to 6 that evidence was adequate to demonstrate
equivalent or superior clinical effectiveness of TMS
compared to ECT
– All 9 voted “equivalent”
 16 to 0 that evidence was inadequate to demonstrate
equivalent or superior clinical effectiveness of VNS
compared to usual care.
9

10. Outcome of TRD report/meeting
 Regional Medicare contractor for New England
changed draft non-coverage policy for TMS to
positive coverage
– First Medicare coverage in the U.S.
– Based on CEPAC recommendation, New England’s leading
TMS researcher offers to perform voluntary coverage with
evidence development
 Regional private health plans likely to revisit policies
over next several months
10

11. Moving Forward
 Next topics
– Bariatric surgery for non-morbidly obese patients
with diabetes or high cholesterol
– Fecal DNA test for colorectal cancer screening
– Future scope of activities
• Add-on academic detailing arm to reach providers
• State-specific “implementation teams” to pick up
immediately following CEPAC meetings
11