This document discusses an exploratory study on how cost, evidence, and comparative effectiveness research data could be used in benefit design by public and private payers. The objectives are to examine how value may be considered, feasible implementation mechanisms, prioritizing treatments within and across diseases, engaging the public, and how the Patient-Centered Outcomes Research Institute could help maximize benefits. Two examples on cancer treatment and drug trials are provided to discuss policy options on coverage. The document also outlines fellowship meetings and opportunities for travel related to the research.

1. Cost, Evidence and Comparative Effectiveness Research Data in Benefit Design –
An Exploratory Study
Harald Schmidt
Fellow,
Fellow Kolleg Forschergruppe, Uni Münster Research Associate LSE Health
Forschergruppe Münster, Associate,
Nuffield Trust, H3 March 11

2. Objectives
• With CER push: (how) will public and private payers consider
g
value in benefit design?
• Implementation mechanisms: what’s feasible and fair?
• Within vs across disease prioritizations: potential?
• What role for public engagement?
• Patient Centered Outcomes Research Institute (PCORI): how
can it help maximize CER benefits?

3. Objectives
• With CER push: (how) will public and private payers consider
g
value in benefit design?
• Implementation mechanisms: what’s feasible and fair?
• Within vs across disease prioritizations: potential?
• What role for public engagement?
• Patient Centered Outcomes Research Institute (PCORI): how
can it help maximize CER benefits?

4. Two examples
Prostate cancer management, Plavix/Effient trial:
Policy spectrum:
• Provide all options – physician/patient judgment
• Differential copays /Value Based Insurance Design (
p y g (VBID)
)
• Other steering (information, counseling…)
• Deny coverage/access
• Other
-> Consensus: no ban, but shared decision making and use of
info.
info Over time move down the ladder (3 5 Y)
time, (3-5

5. Copays and VBID/’top-up’ payments
Pro:
• “employers need it simple” branded/generic concept clear and
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accepted, signaling effect
Con:
• blunt & potentially unfair (Newhouse/RAND),
(Newhouse/RAND)
• operationalizability: “just good for low hanging fruit”?
Key:
• robustness of evidence, admin cost, feasibility (co-pays used
or not… payers vs payer/provider systems)
• Fairness within group (Plavix): don’t penalize victims of
don t
genetic lottery
• Fairness across groups: Who and why? (diabetics….)
• Instead of drugs: focus on choice of providers, wellness
incentives

6. Fellowship meetings and travel oppt
and VBID/’top up’ payments
VBID/ top-up
Sept: Orientation & qualitative methods / NYC
Nov: CMWF Intl Symposium / DC
Jan: IHI/CMWF Fellow Summit / Boston
Feb: Policy mtg / DC
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May: Canada trip
June: final reporting seminar / NYC
Research related travel…