Developing a Pilot Project for Private Sector Coverage with Evidence Development 6.14.10

Developing a pilot project for private sector coverage with evidence development Sonnad SS 1,2, Seidenfeld JD 1 , Bergthold L 1 1 Center for Medical Technology Policy, Baltimore, MD, USA, 2 Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA Research Objectives Coverage with Evidence Development (CED) is a policy tool for health plans to offer provisional coverage for a promising but unproven intervention while data are being collected to generate the evidence needed to inform coverage policy. This study reports on an effort led by the Center for Medical Technology Policy (CMTP) to launch a pilot CED initiative in the private sector. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Conclusions Conducting private sector CED using rigorous research design and involving multiple payers is not without challenge. However, payer representatives remain interested in the possibilities of generating better information for coverage decisions through this mechanism and remain committed to the project. Populations Studied Representatives of CMTP’s multi-stakeholder CED workgroup: Implications for Policy Both CMS and private insurers have used CED with limited success in the past. Previous work by CMTP demonstrated broad support for the concept of CED among stakeholders in the private sector, but unclear leadership for coordinating such a CED project until this pilot effort undertaken by CMTP and participants. Widespread application of CED in the private sector could significantly impact the adoption and dissemination of new technologies in a broader range of patients than those covered by CMS. This could have significant implications for the cost and efficacy of new technology use in the United States healthcare system. Design of a private sector CED pilot Primary Funding Source: California Healthcare Foundation Stakeholder position Name Organization Patient/consumer Larry Sadwin President, Friends of the World Heart Federation Foundation Patient/consumer Susan Goodreds President, MarketPower, LLC Private Health Plans Bob McDonough Head of Clinical Policy Unit, Aetna Private Health Plans Dick Justman National Medical Director, United Healthcare Private Health Plans Virginia Calega VP, Medical management and Policy , Highmark, Inc. Private Health Plans James Adamson Vice President/Chief Medical Officer, Arkansas BCBS Private Health Plans Tricia Nguyen Senior Medical Director, Blue Cross Blue Shield Florida Public Plans Louis Jacques Director, Coverage and Analysis Group, CMS Public Plans Tamara Syrek-Jensen Deputy Director, Coverage and Analysis Group, CMS Self-insured employer Jim Knutson Risk Manager and HR Director, Aircraft Gear Corporation Physician Janet Wright VP for Science & Quality, American College of Cardiology Physician Wells Shoemaker Medical Director , California Association of Physician Groups Clinical Research Eric Stanek Senior Director of Research in Personalized Medicine, Medco Clinical Research Brian Gage Associate Professor, Washington U School of Medicine Clinical Research Steve Kimmel Director, Cardiovascular Epidemiology , U Penn Medicine Government research Yves Rosenberg Division of Cardiovascular Sciences, NHLBI Legal representative Jeff Miles Partner, OBER | KALER Study Design Phase 1: Research and Topic Identification Phase 2: Convene Multi-Stakeholder Workgroup Phase 3: Design Research & Implementation Protocol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Developing a Pilot Project for Private Sector Coverage with Evidence Development 6.14.10

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Developing a Pilot Project for Private Sector Coverage with Evidence Development 6.14.10