Payers for Most Part Wary of Real World Evidence

But some are coming around. That was one of the messages delivered yesterday in Philadelphia at a conference hosted by EyeforPharma, a worldwide company that seeks to keep the pharmaceutical industry relevant by tracking shifting trends. The title of the conference “Real World Evidence & Market Access Summit 2016” bows to today’s hot topic. Put simply, real world evidence (RWE) and post-market surveillance looks at how well new medications do after they’ve hit the market.

Not so good, according to Shalilja Dixit, one of the presenters at the conference. Dixit, who tracks health outcomes for Intercept, said that 49% of drugs do not have the same impact on outcomes that they had in the clinical trial stage. “The time is right for real world evidence to make that 60% to 70%,” Dixit said. “Rising health care costs are not acceptable, especially when outcomes don’t impress.”

Maybe that will impress health plans. Maybe not. David Thompson and Keith Kelly, of InVentiv Health, said that the days of getting effective data from a database are over. The trick is to engage stakeholders through every stage of gathering RWE, from research to design to implementation. “Stakeholder engagement can’t be done in a one-and-done fashion,” said Kelly. “You can’t just say, ‘The answer is E.’”

 Thompson said that, “Treatment patterns and adherence, that’s where real world evidence really shines.” In some clinical areas, such as diabetes, REW has been a “game-changer.”

But not so much of a game-changer that health plans are ready to jump in with both feet. “Payers have a pessimistic view that real world evidence can help them,” Kelly said. “Payers have indicated that the most important benefit of real world evidence for them is better understanding of the cost implications.”

Often payers will question whether RWE is reflective of their particular population. They also question whether RWE captures everything that’s happening with a patient. There are reasons other than therapeutic effectiveness that some medications don’t work (ie. lack of adherence).

That said, some health plans are indeed starting to use RWE. Kelly mentioned Geisinger Health Plan in particular as having a keen interest, as has the Veterans Affairs health care system. Integrated model insurance plans, such as Geisinger and Kaiser Permanente, should be fertile breeding grounds for RWE in the future.

Frank Diamond

Managing Editor

Managed Care magazine

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.