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Aetna Pharmacy Management
Systematic Reviews of Comparative Effectiveness
Payor View
Edmund Pezalla, MD, MPH
Chief Clinical Officer
Aetna Pharmacy Management
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Use of Medical Evidence in the payor context
1. Coverage determination
2. Provider payment policy
3. Determination of quality of care
4. Prediction of practice patterns
5. Guidance for members and providers
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Coverage determination
Request for procedure
Application of clinical policy
Denied: experimental
Covered with evidence development
Covered
•UM
•Copay level
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Coverage for pharmaceuticals
Medical evidence
Copay tier
Step therapy
Prior authorization
•Formulary
•Benefit design
•Out-of-pocket expenses
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Data sources
Published trials
Published reviews
National guidelines
Drug compendia
FDA/regulatory data and labels
Internal data
Unpublished results by mfr and academic centers
Currently used
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Issues
Data developed for other purposes may not answer all of the questions
Small trial size, especially for surgical procedures
Lack of information to help control for confounders
Lack of active comparators in many trials
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Data grading
Current systems promote RCT over all other types of studies
There is no accepted scale for ranking non-randomized or retrospective studies
Methods for combing types of studies are limited
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Payors and grading of evidence
Standardized approaches can:– Increase acceptance
– Improve decision making
– Encourage research and publications
– Allow for use of internal data or increase publication of analysis of that data by payors
