Posts Tagged evidence based medicine

Evidence Based Medicine – Aligning Labs, Clinicians & Payers for Better Diagnostic Decisions

Mark Zubiller, VP of Decision Management at McKesson, talked about value based medicine by driving better diagnostic decisions through collaborative model, aligning labs, clinicians, and payers, at event.

Molecular diagnostic tests identify molecular and genetic markers for an individual patients that help determine potential benefit from a specific, targeted therapy.  Molecular diagnostic tests have become a big buzz word but the area is fraught with challenges.  There isn’t a lot of clinical evidence that support many of these tests which are often based on extreme of a diagnostic marker, so there needs to be more data churning to demonstrate clinical utility of the data.  Second, there is limited point of service information.  Only 20% of molecular diagnostic tests on the market have evidence based guidelines today, although 75% of the providers believe that patients in their practice would benefit from having a genetic test.  As new tests continue to emerge, physicians cannot keep up with information about newer tests and their efficacy.  Third, many of the tests are unidentifiable.  There is no catalogue for identifying the tests, coding information is nonspecific, and payers do not have consistent way to code and pay for these.  Payers require clinical utility for coverage.  This often leads to denials and reapplications and generates a lot of frustration for everyone involved.  Finally, this results in increased paperwork and payer scrutiny.

Currently, market does not have a way to address this challenge and it is stuck between innovation and execution.  There is a great deal of system fatigue, on account of increasing administrative burden, reform compliance etc. but while innovation is greatly needed, it would bring reimbursement shifts, additional administrative challenges, and a need for collaboration among the stakeholders.  Payers, labs, and providers essentially share the same challenge of ensuring that patients get the right care at the right cost, without increased administrative burden.  Existing traditional payer programs operate in silos and do not have a way of engaging providers.  They require expensive manual resources and are struggling with administration, transparency, and consistency.  Lack of collaboration exerts a huge financial burden on both the providers and the payers.  Providers spend $31 billion annually and payers spend $74 billion annually that could be saved, with greater collaboration.

Explaining the McKesson value based care model, Zubiller said, it means “balancing value-based reimbursement with value-based care delivery at the point of care.  As the patient care progresses from care selection to care plan to network selection to reimbursement, point of care decisions happen at each stage that impact cost, care, and value.  Earlier and better decisions would greatly reduce cost, improve care, and provide better value, said Zubiller.  A value based diagnostics strategy has to be based upon collaboration between labs, payers, and providers for identification of tests, for determination of cataloging and coverage, for consistent evidence based payer and lab policies, for decision support rules integrated into EMR, and for sophisticated performance data analytics for payment.

The talk was followed by Q&A.  Explaining the strategy, Zubiller said, McKesson is a business that works with health care stakeholders in every setting and is therefore taking the lead to chart the course towards a stronger more sustainable future, for the entire industry.  McKesson is a leading provider of enterprise information technology solutions, including software, services, automation, and consulting to hospitals, physician offices, imaging centers, home health care agencies, and payers.  With strategic use of IT solutions to bring greater connectivity in the healthcare ecosystem and by leveraging its credibility to bring the stakeholders to the table for collaborative dialog, McKesson hopes to lead implementation of value based care model that would be a win-win solution for payers, providers, labs and for patients.

English: The logo of Mckesson Corporation

English: The logo of Mckesson Corporation (Photo credit: Wikipedia)



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Cancer Pathways, Evidence Based Medicine & What it Means for BioPharma Industry


Ellen Licking, writer and analyst for Real Endpoints, a start-up focused on providing objective information about product reimbursement, discussed “what cancer pathways mean for biopharma industry at

Cost containment in healthcare has emerged as a significant issue and the payers are looking at big cost diseases like oncology to find more effective care options. The use of cancer care pathways is emerging as a strategy to focus on providing efficient care, while also containing costs. Results from existing “cancer pathway” pilots underway at national and regional insurers are becoming available in 2012 and are shedding light on the use of evidence-based medicine to improve outcomes and lower costs. In Europe, they discuss rationing of care. But in the US, it is a more complex issue, given the diversity of stake holders and the necessity for implementing politically appropriate language and behaviors.

Cancer pathways provide an evidence based-approach to care that is based on efficacy (how well the treatment works), toxicity (how toxic is the treatment), and cost. In the event that two drugs provide similar efficacy and toxicity, then the choice comes down to cost. Clear winners for reimbursement, in this approach, are efficacious drugs; for products that are as good, the choice is made based on price. First and foremost, this approach is designed to reduce the existing wide variation in care. Second, it aims to improve outcomes with focus on treatments that provide the greatest survival benefit and the lowest toxicity. Third, these care pathways would contain cost, based on scientific evidence of best care.

These pathways are not commandments in that payers are not mandating providers adopt a certain pathway. To get buy in from physicians, payers are considering waiving the right to prior authorization and programs that allow doctors to share in any financial savings. In one study, the data indicated 35% cost savings for on-pathways patients compared to those not on pathways, while showing no difference in survival outcomes. Real world cost savings, at least initially, are expected to be more modest in the 10-15% range. However, even these savings would greatly contain costs. Cancer pathways are small but growing quickly. Currently, there are an estimated 29 programs in place from a variety of payers. One concern has been that the pathway approach may change how oncologists are paid. Most oncologists are paid in relation to the amount and cost of drugs they prescribe. If payer savings translate into dramatic pay cut for oncologists then it would become challenging to get their buy in. Besides pathways, a few payers are experimenting with episode-of-care, which pays oncologists a single payment for treating patients during a specified treatment period.

What ARE the implications of these changes for THE biopharma industry? Given the dreaded oncology diseases, the treatment programs have traditionally been treated with kid gloves. But under this strategy, there will be clear winners and losers and treatments that are not efficacious will be dropped to make room for possible newer treatment options. While finding winning oncology drugs have always been challenging and will continue to be challenging, in the pathway driven world, it will also be more difficult to establish best in class drugs. Licking offered the recommended options for biopharma industry that include, maintaining focus on first in class drugs given the advantage to first to market, redefine meaning of best in class based on not just clinical efficiency but based on endpoints important to payers, in consideration of efficacy, to focus on price in addition to quality of life issues, and consider risk-sharing schemes that are tied to adherence medtrics or provide clear cost information such as Astrzeneca’s single payment scheme for Iressa. The talk generated a great deal of interest and discussion and was followed by Q&A. Ellen Licking can be contacted at; You can learn more about Real Endpoints at .


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