"how insurers make diabetes coverage decisions" at the 2014 diabetesmine innovation summit
DESCRIPTION
Amanda Bartelme, Director of Reimbursement at Avalere Health (and a type 1 herself), explains how healthcare coverage decisions are made at the 2014 DiabetesMine Innovation Summit at Stanford School of Medicine.TRANSCRIPT
How Insurers Make Diabetes
Coverage Decisions
Prepared for The DiabetesMineTM Innovation Summit
Amanda Bartelme
November 2014
Key Questions We’ll Cover
2
● Who makes decisions on what healthcare is covered?
● What information is used to make those decisions?
● How can patients and advocates influence those decisions?
A Brief History of Health Insurance
3
How did we end up where we are today?
By 1958, 75% of
Americans hold
some form of
private insurance
1950s
First “Health”
Insurance
emerges,
replaces lost
wages rather
than covering
medical bills
Concept of health
insurance takes
root, supply and
demand increase
Birth of
Blue Cross
and Blue
Shield
1920s 1930s 1940s
1965- Medicare &
Medicaid
Established
1960s
Comprehensive
Major Medical
policies introduced
1970s
Managed
Care
introduced
1980s 1990s
2010- ACA
enacted
2000s
1996- HIPPA
Enacted
Advances in care
improve outcomes
while continuing to
drive costs higher
Key Areas of Focus for Health Insurers
4
Overarching goal in making coverage decisions is to determine if a
therapy is “reasonable and necessary”
COST VALUE
BENEFICIARY ACCESS
PLAN
DECISIONS
5
Health Insurance Oversight Influences Coverage
Decisions
While Medicare and Medicaid have somewhat limited flexibility in making coverage
decisions based on the law, private insurers face few coverage requirements
PRIVATE INSURERS MEDICARE & MEDICAID
● Congress establishes what Medicare
covers in law
o Law specifically states that certain
items MUST be covered
o Medicare has flexibility to determine
coverage of other items under
“Benefit Categories” established in
the law
● Medicaid jointly overseen by Congress
and state governments
● Federal and State laws establish broad
requirements
o Historically, many plans offered by
private insurers are often exempt
from mandated coverage of specific
items or services
● ACA added patient protections for
coverage and out-of-pocket costs for
certain items and services
Laws governing private insurance are
typically not prescriptive in terms of
covering specific therapies
By law, Medicare must cover meters, test
strips, insulin, and all items related to
injecting insulin
Key Private Payer Decision-Makers
6
Coverage decisions are made on the population, not individual patient, level
Role Responsibilities Features / Characteristics
Medical Director
● Provider relations
● Quality management
● Utilization management
● Medical policy
● Board-certified physician
● Spectrum of involvement parallels intensity of payer medical management
o Simple claims review to establishing medical policy
Pharmacy
Director
● Pharmacy benefit management
● Contain pharmaceutical costs without depriving individuals of necessary medicine while improving quality
● PharmD or RPh
● Issues arise when Pharmacy and Medical Director do not coordinate medical and pharmacy benefits to lower resource utilization and medical costs
● Usual manufacturer contact with private plans
Pharmacy and
Therapeutics
(P&T)
Committee
● Formulary development and revision
● Unearthing abnormal prescribing patterns
● Membership:
o Pharmacists
o Medical Director
o Contractor, finance, and legal representation
o Physicians, especially high prescription-use specialties (PCPs, internal medicine, pediatrics)
o Infectious disease representatives (ad hoc)
Many Factors Influence a Plan’s Coverage Decision
7
CoverageDecision
Efficacy
Plan MemberExpectations/
Feedback
Productivity, Satisfaction,
Quality of Life
PhysicianSupport /
Guidelines
Safety
PremiumImpact
ManufacturerContract
RegulatoryIssues
Cost-Effectiveness
Quality
Disease MgmtPrograms
Effectiveness
AcquisitionCost
Politics andPublic Image
Clinical TrialResearch
8
What Kind of Evidence Is Most Important to Payers?
Clinical / Patient
Population
InformationEconomic
Studies
Technology
Assessments
Outcomes
Studies
Least Important Most Important
For diabetes treatments, data on HbA1c improvement, helping patients achieve
glycemic control goals, and maintaining glycemic control are of particular interest
Health Plan Decision Influencers
9
Coverage Decisions
In-Network Providers &
Physician Experts
Direct Customers (e.g., employers)
Government
Beneficiaries
Best Practices for Being Your Own Advocate
10
1. Determine your plan’s coverage policy
o Search website or request it be sent to you
2. Be prepared and persistent
o Be aware of prior authorization and other requirements for coverage
3. Get informed and get help
o Contact your plan (case manager), provider, and manufacturer to solicit help
4. Communicate the medical urgency of your request
o Be prepared to provide letters of medical necessity, journal articles, and treatment guidelines to support your case
5. Formally file for case-by-case coverage if necessary
o Submit all documentation supporting your request to the plan’s medical director
6. Know your plan’s appeals process
o Following the plan’s process avoids denials based on technicalities
7. Be prepared to appeal, appeal, appeal!
In addition to personally contacting your insurer, enlist your employer/benefit
manager and physician(s) to advocate on your behalf