Agenda Darren Coffman Oregon Health Evidence Review 3:00 3:20pm - - PowerPoint PPT Presentation

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Agenda Darren Coffman Oregon Health Evidence Review 3:00 3:20pm - - PowerPoint PPT Presentation

Dec 07, 2022 398 likes •765 views

National Academy For State Health Policy Learning Collaborative From Engagement to Evidence: Using PCOR & CER to Inform State Policymaking July Group W ebinar State Leaders in Evidence-based Policymaking July 13, 2016 3-4pm Eastern

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T his wo rk was suppo rte d thro ugh a Patie nt-Ce nte re d Outc o me sRe se arc h I nstitute (PCORI ) Pro gram Award (E A-2159-CHPD).

National Academy For State Health Policy Learning Collaborative From Engagement to Evidence: Using PCOR & CER to Inform State Policymaking

July Group W ebinar

State Leaders in Evidence-based Policymaking

July 13, 2016 3-4pm Eastern Call-in: 866-740-1260 Enter access code: 8746524

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Agenda

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3:00 – 3:20pm Darren Coffman Oregon Health Evidence Review Commission (HERC) 3:20-3:40pm Dan Lessler and Gary Franklin Washington State Agency Medical Director’s Group (AMDG) 3:40-4:00pm Group discussion / Q&A

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  • Darren Coffman

Director, Health Evidence Review Commission

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Commission History

  • Oregon Health Plan Legislation passed in 1989 (SB 27)
  • Health Services Commission (1989-2011)
  • Health Evidence Review Commission (2012-Present)
  • 13 Governor-appointed, Senate-confirmed Members

– 5 Physicians ̶ Complimentary & alternative – Dentist medicine – Public health nurse ̶ Retail pharmacist – 2 consumers ̶ Insurance industry – Behavioral health

  • Volunteers, reimbursed for travel expenses
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  • Commission established to create Prioritized List, funded

by 50% GF/50% FF, shoestring budget

  • “Not subject to alteration by any other state agency”
  • Legislature draws funding line subject to CMS approval

– Expanded coverage to 100% FPL in 1994

  • List represents “health services ranked by priority, from the

most important to the least important, representing the comparative benefits of each service”

  • “Commission shall actively solicit public involvement through a

public meeting process”

  • “Consider cost effectiveness as well as clinical

effectivenessusing peer-reviewed medical literature ”

Medicaid Expansion

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Assumptions of the List

  • Every person is entitled to a diagnosis

– Diagnostic office visit(s) – Imaging/lab – Biopsies

  • Each covered condition includes

– Prescription drugs – DME and supplies – Other ancillary services

  • Services Recommended for Non-Coverage do not appear
  • n list

– Excluded in Department of Medical Assistance Programs administrative rules (e.g., infertility treatment) – Cosmetic services – Experimental treatments – Not effective for any condition

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Sample Prioritized List Line

Line number (funding line is 476 for this list)

If the diagnosis and the procedure appear on the same line, the service is covered said to “pair” (though it may be subject to a guideline note or coding specification) If the line number where it “pairs” is above the funding line, it’s covered.

Condition/Treatment descriptions (plain English approximations) Reference to guideline notes

Line: 183 Condition: ACUTE LEUKEMIA, MYELODYSPLASTIC SYNDROME (See Guideline Notes 7,11,12,14) Treatment: BONE MARROW TRANSPLANT ICD-10: C88.8,C90.10-C90.12,C91.00-C91.02,C95.00-C95.02,D46.0-D46.1,D46.20-D46.9,D47.1,D47.3, D61.810,Z48.290,Z52.000-Z52.098,Z52.3 CPT: 36680,38204-38215,38230-38243,64505-64530,86828-86835,98966-98969,99051,99060,99070, 99078,99184,99201-99239,99281-99285,99291-99404,99408-99416,99429-99449,99468-99480, 99487-99498,99605-99607 HCPCS: G0396,G0397,G0406-G0408,G0425-G0427,G0463,G0466,G0467,S2142,S2150,S9537

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Examples of Rankings in 2016

Funded Lines:

26 Schizophrenia 51 Appendicitis 143 Glaucoma 195 Breast Cancer 348 Dental Caries (Fillings) 360 Closed Fracture of Extremities 373 Strep Throat 415 Migraine Headaches

Unfunded Lines:

479 Chronic Otitis Media 516 Esophagitis and GERD (long-term medical therapy) 527 Uncomplicated Hernia 565 Transplant for Liver Cancer 609 Sleep Disorders w/o Apnea 617 Common Cold

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Use of Prioritized List by CCOs

  • CCOs (contracted plans) consistently report they:

– Use the Prioritized List to deny coverage for treatments with little

  • r no clinical benefit

– Use the clinical practice guidelines included in List to manage services by according to disease severity, step therapy, etc. when benefits are being limited to specific populations – Save administratively from having to do their own evidence review, which would be added costs in order to set their coverage policies

  • The List provides for more statewide consistency in the

provision of benefits across the CCOs & FFS program

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Public Engagement

  • All meetings public
  • Four statewide forums held at times of critical input
  • Topic suggestions may be given directly to staff
  • Allow unsolicited brief presentations (with notice)
  • Ad hoc verbal comments are generally very limited
  • 4000 member listserv
  • Expanded outreach during biennial review of List

– Interim modifications twice per year

  • Monthly updates/feedback at meetings of medical

directors of contracted plans (CCOs)

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Evidence-Based Process

  • Decisions historically based on expert opinion.

Evidence-based medicine has shifted coverage decisions to rely on systematic reviews and quality trials where possible.

– Supporting evidence needed to place new services on list – Evidence of harm or ineffectiveness can be used to removed existing services from list

  • Cost-effectiveness considered where available when
  • utcomes are similar between treatments
  • Incorporate recommendations of coverage guidances

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Coverage Guidances

  • In-depth review of more challenging, emerging clinical

issues faced by CCO medical directors

  • Recommendations in the guidances are intended for

both private and public payers and purchasers

– 46 coverage guidances in last two years have resulted in 42 updates to Prioritized List for OHP – New work to identify how decision support tools can be used to guide providers/patients in encouraging most clinically effective/cost-effective care

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HERC Subcommittee Structure

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HERC VbBS

Value-based Benefits Subcommittee

EbGS

Evidence-based Guidelines Subcommittee

HTAS

Health Technology Assessment Subcommittee

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Topic Selection Report Development Review and Approval Monitoring

Coverage Guidance Process Overview

Topic Identification

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EbGS/HTAS review

  • 7-day comment period on scope statement
  • Ad hoc expert appointed if needed
  • Review staff initial draft report
  • Can modify or request additional research,

then post for comment

Public comment period

  • 30 days, posted on HERC website and

announced through HERC e-gov delivery service

  • Maximum of 1000 words plus citations per

commenter

Report Development

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Review public comment

  • Public comment disposition document responds to each

comment received

  • HTAS/EbGS may revise draft recommendations based on public

comments, and may post for additional 21-day comment period

  • Approves final draft

Review by VbBS

  • Reviews coverage guidance, and may make changes to

Prioritized List which guides coverage for the Oregon Health Plan

Review by HERC

  • 30-day public notice
  • HTAS/EbGS approved draft posted 14 days prior to meeting
  • May modify report and associated prioritization changes prior to

approval or request further work

Report Development (cont’d)

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Coverage Guidance Example

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GRADE-Informed Framework

(Additional outcomes omitted for brevity)

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EVIDENCE-BASED POLICY IN WA STATE

NASHP PCOR/CER LEARNING COLLABORATIVE JULY 13, 2016

Gary M Franklin, MD, MPH Medical Director WA Dept Labor and Industries Dan Lessler, MD, MHA Chief Medical Officer WA Health Care Authority Co-Chairs, WA Agency Medical Directors Group (AMDG)

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WA STATE AUTHORITY FOR EVIDENCE-BASED DECISIONS

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AGENCY MEDICAL DIRECTORS GROUP: PARTICIPATING AGENCIES

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Federal Oversight Drugs Medical Devices Surgical Procedures

Required for FDA approval 2 prospective, placebo controlled RCTs Substantial equivalence to preexisting device No approval requirements Study outcomes Disease-related endpoints Engineering performance only None Published studies with patient-oriented endpoints? Common Uncommon Not Considered Patient population Narrowly defined set of conditions

(e.g., depression, dementia)

Varies widely

(e.g., implantable defibrillators, laparoscopes)

Not Considered Post-marketing evaluation? Sporadic, sometimes high quality Rare, usually low quality None

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AMDG PARTICIPATION IN STATEWIDE EVIDENCE-BASED MEDICINE EFFORTS

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AMDG OUTPUTS

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2015 WA AMDG GUIDELINE ADVISORY COMMITTEE

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Questions

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