Make coverage decisions with comparative effectiveness research

Comparative effectiveness research (CER), which helps payers determine plan coverage options based on the effectiveness of certain treatments, could improve the entire healthcare industry, according to Applied Clinical Trials.

"CER is going to be a fundamental game changer in how we practice medicine and will help us get access to the right medicines at the right time for the right patient," Nancy Dreyer, chief of scientific affairs and senior vice president at Quintiles Outcome, told the journal.

The research tool is particularly beneficial for payers because it helps them decide whether they should choose to cover a particular drug instead of another. Moreover, if payers can fully implement CER, they will be able to make coverage choices based on specific situations. For example, they can base decisions to pay for a certain drug for one member on his other comorbidities.

Given the recent debate over new specialty medications like the hepatitis C drug Sovaldi, which costs about $1,000 per pill and more than $80,000 total, CER could help payers selectively cover these expensive drugs.

"It's not as simple as, 'This drug costs more.' Payers have a surprisingly long view," Dreyer said. "They want to know over the long term is this benefit really going to make a difference."

And the good news is that with the rise of sharable electronic data, CER is improving. "There's an exponentially growing interest in this area, but we traditionally didn't know what data to use," she added. "The only data that was readily available was insurance claims data. Now that there's so much more electronic medical record data available, we're starting to marry those and have the real clinical detail along with, 'Did you actually fill the prescription?'"

To learn more:
- read the Applied Clinical Trials article