Using best treatments to shape plan design

Two studies released last week questioning the use of stents in some patients with heart disease have attracted the attention of employers and medical academics working on ways to use medical efficacy to influence the design of benefit plans.

Researchers say more than 1 million stent procedures are performed each year, which health care experts say cost U.S. employers billions of dollars annually.

The studies involving stents--mesh tubes inserted into blocked blood vessels to prop them open--were released at the annual meeting of the American College of Cardiology in New Orleans. The first study, presented by Dr. William Boden of Buffalo General Hospital, found that stents provided no extra benefits compared with drugs alone for patients with stable heart disease. The second study, by a team of researchers at the Mayo Clinic, found patients were more likely to get drug-eluting stents--those coated with medication to help prevent arteries from blocking again--if they have private, third-party health insurance.

While early evidence-based health care plan models focused primarily on drug interventions, they are expected to evolve to not only allow plan sponsors to dictate which medical services will be covered, but also which plan participants will receive those services on a free or discounted basis.

Although self-insured employers are the ultimate decision makers regarding what their health plans cover, until recently most have relied on benefit consultants and third-party administrators to help them decide the content of their benefit plans, said Bruce Kelley, leader of health data solutions at Watson Wyatt Worldwide in Minneapolis.

But as health care costs continue to escalate, employers are becoming more involved in setting coverage parameters. In such cases, they are looking to medical literature to help them decide what to cover and what to exclude, industry experts say.

For example, after research determined that removing diseased portions of the lung in patients with advanced chronic obstructive pulmonary disease did not improve patients' quality of life, many employers began excluding such treatment from their benefit plans, Mr. Kelley said.

Conversely, some employers have begun covering bariatric surgery to treat obesity because "the evidence suggests that there is a group of individuals where bariatric surgery is a good alternative," said Ken Sperling, senior vp for national accounts at CIGNA Healthcare in Bloomfield, Conn.

Another way employers have begun applying evidence-based medicine in plan design is by generally substituting generics for prescription drugs, or lowering copayments for plan members using high-performance networks of providers who adhere to medical protocols and, therefore, produce the best outcomes, Mr. Sperling said.

A few employers recently took a further step by experimenting with what is called evidence-based plan design, which is defined as offering more generous benefits for prescription drugs and medical services that are supported through clinical evidence and lesser benefits for those drugs and services that are unproven and/or unsafe given a specific patient's needs.

Achieving the highest ROI

"Most employers have already cost-shifted as much as they can. So now they have to come up with creative solutions," said Dr. A. Mark Fendrick, a professor of internal medicine at the University of Michigan in Ann Arbor and director of the Center for Value-Based Insurance Design, which was formed in 2005 to support this concept. "To ultimately get to the highest ROI for health care dollars, we need to target our efforts on both patient and physician incentives in a specific, clinically nuanced way."

Although the initial intent of evidence-based design was to reduce barriers to care, "over time, "evidence-based plan design will evolve to start addressing wasteful unproven interventions," said Jennifer Boehm, a principal at Hewitt Associates Inc. in Atlanta. "The plan is to exclude services that are not medically necessary."

For example, in implanting stents, an evidence-based plan would limit coverage to only those patients who would gain the most benefit, such as those having heart attacks, Dr. Fendrick said.

Emerging medical information technology, such as electronic health records, will help facilitate evidence-based plan design, said Dr. Lonny Reisman, chief executive officer of New York-based ActiveHealth Management Inc., which has been working with Marriott International Inc. on designing its benefit plan.

"What we're asking the insurers and (pharmacy benefit managers) to do is administer the claims based on information that we provide, and compare each member's individual data against evidence-based literature," he explained.

Indeed, sophisticated information technology could tell a plan administrator that a patient who is prescribed a beta blocker for heart failure should have no copayment, but that another patient taking the same drug for performance anxiety should have a copay, Dr. Fendrick said.

Ultimately, evidence-based plan design will tailor coverage to an individual's specific health care needs, he said.

"We're on the verge of a very innovative and emerging era," said Ms. Boehm. "I really do think this is about having enough real-time data and clinical decision support to identify what's right for one patient but might not be right for another. Because we're individual biological beings, this is where we have to move to. It's going to be an evolution as with all things in this arena. But we're on our way."