Convincing the Payers. Saurabh Jha MBBS Assistant Professor of Radiology, University of Pennsylvania

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1 Convincing the Payers Saurabh Jha MBBS Assistant Professor of Radiology, University of Pennsylvania

2 Objectives How the Affordable Care Act (ACA) changes the incentives for the payers Methods to show effectiveness Thinking outside the box to value imaging

3 Payers Government a) Medicare b) Medicaid Insurers for the large group market Insurers for the small group/ individual market Out of pocket paying consumers

4 The ACA and the Insurers Essential Medical Benefits Preventive services and Wellness programs Fixed Medical Loss Ratios

5 Essential Health Benefits Pre-specified minimum coverage At the discretion of the Health and Human Secretary Likely to be broad-based statement ( insurer must cover essential cardiovascular services when needed ) rather than a specific statement ( insurer must cover cardiac MRI in the initial work up for heart failure )

6 Preventive services and Wellness programs No cost sharing for preventive services Level of evidence required likely to be high Promulgation of wellness programs Rebates of up to 50 % on the premiums for participation in wellness programs

7 Do the results from calcium scoring CT influence health promoting behavior? Attention to modifiable risk factors. O Malley, JAMA, 2003: NO Adherence to statin therapy. Kalia, Atherosclerosis. 2006: YES Initiation and adherence to aspirin. Arakzai, Am J Cardiology, 2008: MAY BE

8 Medicare Likely to lead by example Cost not explicitly a factor Effectiveness likely to be weighted by disutilities (e.g. anxiety from incidental findings) Independent payment advisory board ( MedPAC on steroids )

9 The ability to diagnose is not enough. The diagnostic test must be shown to improve outcomes in the population in which it is used. Improved outcomes = improved quality associated life years

10 What makes an effective imaging modality? Diagnostic accuracy is necessary not sufficient - The disease in question is treatable and foreboding without treatment - The treatment (or the next step) is not seamless and has its own complications - The imaging should alter clinical decision making

11 Methods to show effectiveness Randomized controlled trials Secondary databases Economic models

12 Randomized controlled trials National Lung Screening Trial Coronary CTA in the ED Coronary CTA versus SPECT

13 National Lung Screening Trial RCT Multi-center $250 million Trial stopped because of the effect size 20 % relative risk reduction (NEJM, 2011) The applicability of the results to typical practice is mixed (Sox, NEJM)

14 Coronary CTA in the ED for low and intermediate risk patients for acute coronary syndrome ACRIN 4005 (Litt, NEJM 2012) ROMICAT II (Hoffman, NEJM, 2012) Coronary CTA versus usual care Metrics: safety, ED resource utilization, downstream utilization Did not pit against do nothing

15 Redberg, Editorial, NEJM, 2012 The underlying assumption.is that some diagnostic test must be performed before discharging these lowintermediate-risk patients from the emergency department. This assumption is unproven and probably unwarranted Stated differently: you can miss a few cases of ACS. That s fine. Tension between the generals and the foot soldiers (idealism and reality)

16 RCTs comparing diagnostic tests Patients randomized not just to different diagnostic tests but different diagnostic arms and treatment strategies contingent on the test result. This introduces challenges in maintaining fidelity of clinical decision making. In the current RESCUE trial which compares cardiac CT to SPECT for suspected chronic stable angina patients who have obstructive CAD should be medically managed as per the findings of the COURAGE trial.

17 Secondary databases Medicare 5 % files. - Only 45 % of patients who undergo elective catheterization undergo a gatekeeper test (Lin, JAMA, 2008) - Rate of revascularization is proportional to the rate of diagnostic angiography (Lucas, Circulation, 2008) High rate of negative catheter angiograms (Patel, NEJM, 2010) Association; lack of nuance; directionality difficult to determine

18 Economic Models Decision models Populate models with numbers (prevalence, test characteristics, quality associated life years)

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20 Cost effectiveness versus comparative effectiveness Let them have cake (if cake is evidencebased) No costs per QALY threshold (e.g. $50, 000 per QALY) Numbers needed to treat/ screen a proxy for costs Technology A produces life years and Technology B produced life years. Should we pay for Technology A?

21 Comparative effectiveness More arbitrary Throwing the baby out instead of the bathwater Rationing is a fact of life

22 Virtual Colonoscopy ACRIN CT colonography trial (NEJM 2008) Why did CMS deny coverage for Virtual Colonoscopy? In an unprecedented endorsement of evidence-based medicine.. (Dhruva, NEJM, 2009) The studies failed to show effectiveness in the Medicare population! (incidental findings) ACR lobbying for passage of virtual colonoscopy bill (4165)

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24 The diminishing marginal value of incrementalism Think disruptive innovation Scar imaging in CMR has disrupted Coronary MRA is incremental Stress MRI is incremental

25 The problem with incrementalism If the incremental effect size is low (AUC 0.89 versus 0.91) large number of patients needed to show a small difference Ok, so stress MRI is slightly more accurate than SPECT, should we replace all SPECT scanners?

26 Knowing for the sake of knowing The demonstration of late gadolinium enhancement on cardiac MRI in patients with hypertrophic cardiomyopathy and dilated cardiomyopathy heralds a higher mortality (Moon, JACC, 2003) So what? Prognosticate with a purpose

27 Putting the cart before the horse Choose a strong horse (MRI to guide appropriate patients for prophylactic ICD/ cardiac resynchronization therapy) Beware of the weak horse (stress imaging for ischemia) Don t rush the horse with potential prematurely (plaque imaging for vulnerability of plaque)

28 Courage to avoid a diagnostic test COURAGE trial: patients on medical therapy did just as well as patients who had percutaneous coronary intervention (Boden, NEJM, 2007) - why perform a catheter angiography? The ISCHEMIA trial aims to determine if those with inducible ischemia benefit from PCI over medical therapy. - if not benefit why perform a diagnostic test for suspected CAD at all?

29 Similia Similibus Curantur If insurers are limited in making money they might want to save money Show that imaging can save money - Gate keep expensive therapy (e.g. ICD/ CRT/ PM) - Efficient diagnostic pathways - Reduce downstream costs - Encourage healthy behavior - Disruptive innovation

30 Consumers Willingness to pay surveys How much do you value diagnostic certainty? How much do you value promptness with diagnosis? Set prices intelligently, one which you have a reasonable chance of recuperating when insurance declines

31 What is the Value of Imaging?

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33 Diamond-Water Paradox The paradox of value Even though water is more useful than diamonds, diamonds are priced higher Ubiquity of water; low marginal cost for an additional unit of water Bottom line: Imaging cannot be as ubiquitous as water and command the price of diamonds.

34 Pitfalls and Challenges Incrementalism Not enough disruption Going head to head with the natural history of the disease Thinking of value only in terms of quality associated life years Prognosticating without a purpose Defining value