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Translating Comparative Effectiveness Research into Medicaid Payment Policy: Views from Medical and Pharmacy Directors

The National Pharmaceutical Council supported a survey of Medicaid medical and pharmacy directors to better understand how policy makers in the state Medicaid programs view comparative effectiveness research (CER) and how they use this research in setting coverage policy. The survey details were published as part of a peer-reviewed study, “Translating Comparative Effectiveness Research into Medicaid Payment Policy: Views From Medical and Pharmacy Directors,” in the March 2015 issue of the Journal of Comparative Effectiveness Research.

Sixty medical and pharmacy directors from 46 states responded to the survey and provided their perspectives on CER:

  • Usefulness of evidence. Nearly 90% said they used randomized controlled trials, systematic reviews and consensus statements from national professional societies in setting policy. About three-quarters used expert opinion, and over half used published observational studies from external sources or patient experience/consumer advocacy.

  • Effects of new CER on medical and pharmacy policies. Nearly 95% of respondents were “very” or “somewhat” likely to recommend a change in coverage policy if new CER evidence showed a currently covered product had more harms than benefits or if a new product was found to be less clinically effective than a currently covered one. Ninety-five percent were at least somewhat likely to limit coverage of a new treatment that was shown to be less cost effective than a current treatment.

  • Consideration of heterogeneity. When asked how often they considered heterogeneity (individual patient differences) when setting coverage policies, respondents reported “usually” or “always” half the time or less, with 13%-31% answering “don’t know/not applicable.”

  • Confidence in CER sources. The sources of CER evidence with the highest level of confidence by directors were the National Institutes of Health, the Agency for Healthcare Research and Quality and the Drug Effectiveness Review Project.

  • Barriers to using CER. The two barriers presenting the biggest problems were “lack of high quality research” and “lack of conclusive results.” In addition, approximately half of respondents thought that “legislative mandates” and the “lack of an independent body that provides legitimacy to interpretations of CER results” were important barriers. 

  • Effects of CER on U.S. health care policy. Respondents were overwhelmingly in agreement that in the future, CER would result in better clinical decision-making and improved quality and health care value. Only about 50% of respondents thought that CER would actually reduce costs.

With the increased awareness of the Patient-Centered Outcomes Research Institute and other sources of CER, and the wider use of set standards for carrying out CER, there is a great chance that CER will be better executed and will receive higher acceptance from policy makers in setting healthcare policy.

The survey was conducted on behalf of NPC by the University of Massachusetts Medical School’s Office of Survey Research between October 2012 and May 2013.

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