Payers

To improve formulary design processes and support payers in providing more effective healthcare, policy makers should consider involving commercial payers in the development of comparative effectiveness research and creation of research and treatment guidelines.

Comparative effectiveness research and pragmatic clinical trials are valued methods to address the limitations of traditional randomized trials, answer questions of cost-effectiveness or noninferiority, and inform data-driven dialogue and decision making by stakeholders.

As physicians enter a new world of therapies for molecularly defined lung cancer, it will be critical for hospitals, drug companies, and insurance companies to work out the interplay of molecular testing and coverage for expensive therapies that are effective but only in smaller, defined groups of patients.

Journal of Oncology Practice (JOP) and The American Journal of Managed Care (AJMC) join efforts to highlight work focusing on issues affecting payers and providers.

Mr. Geraghty points out a variety of ways to engage a health plan's members.

Dr. Richard Rainey, Executive Medical Director at Regence Blue Shield in Idaho, talks about some of the factors that go into coverage decisions as they relate to genetic testing.

Marcus D. Wilson, PharmD, President, HealthCore, states that there is variability within and between different organizations that utilize comparative effectiveness research.

Aaron S. Kesselheim, MD, JD, MPH, Assistant Professor of Medicine, Harvard Medical School; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, explains that academic detailing is the best way to deliver evidence-based information to various parties.

Health plan accounting data are used to test how well the CMSHCC risk adjustment system tracks relative costs of treating various diagnoses: not very well.

Three approaches to prospective patient identification for care management programs were compared: predictive modeling, selection by primary care physician, and a combination of both.