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Systematic Reviews of Comparative Effectiveness

Systematic Reviews of Comparative Effectiveness. Payor View Edmund Pezalla, MD, MPH Chief Clinical Officer Aetna Pharmacy Management. Use of Medical Evidence in the payor context. Coverage determination Provider payment policy Determination of quality of care

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Systematic Reviews of Comparative Effectiveness

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  1. Systematic Reviews of Comparative Effectiveness Payor View Edmund Pezalla, MD, MPH Chief Clinical Officer Aetna Pharmacy Management

  2. Use of Medical Evidence in the payor context • Coverage determination • Provider payment policy • Determination of quality of care • Prediction of practice patterns • Guidance for members and providers

  3. Coverage determination Request for procedure Application of clinical policy Covered with evidence development • Covered • UM • Copay level Denied: experimental

  4. Coverage for pharmaceuticals Medical evidence Copay tier Step therapy Prior authorization • Formulary • Benefit design • Out-of-pocket expenses

  5. Data sources • Published trials • Published reviews • National guidelines • Drug compendia • FDA/regulatory data and labels • Internal data • Unpublished results by mfr and academic centers Currently used

  6. Issues • Data developed for other purposes may not answer all of the questions • Small trial size, especially for surgical procedures • Lack of information to help control for confounders • Lack of active comparators in many trials

  7. Data grading • Current systems promote RCT over all other types of studies • There is no accepted scale for ranking non-randomized or retrospective studies • Methods for combing types of studies are limited

  8. Payors and grading of evidence • Standardized approaches can: • Increase acceptance • Improve decision making • Encourage research and publications • Allow for use of internal data or increase publication of analysis of that data by payors

  9. Thank You Ed Pezalla Aetna pezallae@aetna.com

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