Why Evidence Matters to Public Policy Makers and An Introduction to CER, PCOR and PCORI

1. Why Evidence Matters to Public Policy Makersand An Introduction to CER, PCOR and PCORI Leah Hole-Marshall, Medical Administrator, Department of Labor and Industry, Washington; Member, Board of Governors, PCORI

2. Overview: • Why (I think) Evidence Matters • Why Evidence Matters to State Policy Makers • How WA State Policy Makers are Using Evidence Today • A Reliable, Relevant Source of Evidence Does Evidence Matter To You? Pictured: PCORI Board of Governors (March 2012)

3. Why Use Evidence? The State Health Policy Maker Dilemma • We spend more per capita on healthcare than any other country in the world. • In FY2010 WA spent $7 billion State General Fund to provide medical coverage to 1.5 million Washington residents … about 33% of the budget. • Nationally, in 2007, total health care spending was 15% of gross domestic product compared to just 4% in 1960 • Average annual insurance premium 7.3% increase over last 20 years (Mercer). 0utpaces wage and overall inflation increases by avg. 3% annually • There are significant variations in quality and costs across the nation. • There is increasing evidence of an inverse relationship between quality and cost.

4. What is WA (and the US) buying with its soaring Health Care budget? More Coverage? • A record 876,000 Washingtonians without health care (spike of 21% in 2009) and Up from 593,000 in 2006 (nearly 1 in 5) Better Health? • Poor outcomes: national rankings aren’t even in top ten • the United States spends more on health care than any other country, but ranks 28th in life expectancy and 37th in health system performance. Higher Quality Services? • At least 20 to 30 percentwaste of health expenditures on services that do not improve or extend life. • Even known “right care” delivered only 55 percent of the time to adult patients Well-designed, well-conducted studies of the effectiveness of most health care services are the exception, and the available research evidence falls far short of answering many questions that are important to patients and providers. IOM: Knowing what works. 2008.

6. Dartmouth Atlas Identified Issues:Unwarranted Variations In Health Care Use • There are structural problems in the current system • Underuse of Effective care and Quality Variation • Align pay incentives; Chronic care management focus; Facilitate Patient information exchange; Wellness Promotion • Overuse of Supply Sensitive Care • Manage Capacity, Reward quality not volume, Promote Conservative Practice Patterns • Misuse of Preference Sensitive (Discretionary Treatments) • Outcomes Research and Shared Decision Making • The Atlas points to three strategies • Improving the scientific basis of care delivery • Promoting the growth of organized, accountable care • Shared savings programs- to reduce overuse and improve coordination Wennberg, et al. http://www.dartmouthatlas.org/atlases/Unwarranted_Variations.pdf

7. HOW DO WA POLICY MAKERS USE EVIDENCE TODAY? WA State Agency Purchasers: Cutting edge programs • Prescription Drug Program • Preferred drug list used by PEBB, Medicaid, and workers compensation programs • Patient decision Aid - Pilot • Focus on high-variation, preference-sensitive areas that involve multiple options and tradeoffs, e.g. cardiac disease; breast & prostate cancer • Health Technology Assessment • Use evidence, transparent process, and practicing clinicians to make coverage decision based on evidence of effectiveness, safety, and cost-effectiveness. • Opioid Dosing Guidelines • Medical Necessity Language tied to Evidence Rating • Advanced imaging management • Bree Collaborative

8. HTA Outcomes

9. HTA Measures • Summary Comparison of HTA Decisions and Private Insurers: • Same as Private (some occur before, some after) - 47% • Private Insurer is Less Restrictive - 22% • Private Insurer is More Restrictive - 9% • Private Insurer does not have published policy - 18%

10. Why Evidence MattersRELIABLE INFORMATION NEEDED • Patients and their caregivers want to know: • will it work for me (my child/parent/loved one) • what are the downsides • what options do I have; what are the trade-offs • what can I expect to happen long/short term • what can I do • Health Care Providers want to know: • Which patients do best with what treatment • What order should I try different treatments in • What will this test tell me, can I depend on it • What complicating or contraindication do I need to watch for • Policy-Makers Want to Know: • that the care patients receive is safe • that the care patients receive is effective, and • that the care patients receive (and you/taxpayers pay for) is of value

11. Why Evidence Matters: Compare Evidence Decision to some Alternatives • Patients Decide by: • Web testimonials; friends/relatives • Doctor advice; advertisements • Providers Decide by: • Eminence or consensus of community • Experience: what worked for other patients • Others decide: organizational policy, industry reps • Policy Makers Decide by: • Cuts in payment for services (across the board or targeted) • Restricted access based upon utilization and process measures or cuts to types of service or condition • Reduce people covered • Legislative mandate / political decisions

12. Our Mission PCORI helps people make informed health care decisions, and improves health care delivery and outcomes, by producing and promoting high integrity, evidence-based information that comes from researchguided by patients,caregivers and the broader health care community. Pictured: PCORI Board of Governors (March 2012)

13. “The purpose of the Institute is to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis that considers variations in patient subpopulations, and the dissemination of research findings with respect to the relative health outcomes, clinical effectiveness, and appropriateness of the medical treatments…” Source: Affordable Care Act. Subtitle D—Patient-Centered Outcomes Research Institute PUBLIC LAW 111–148—MAR. 23, 2010

14. We Use Engagement as a Path to Rigorous Research

15. Our National Priorities for Research

16. Our Growing Research Portfolio Total number of research projects awarded to date: 197 Total funds committed to date: $273.5 million Number of states where we are funding research: 36 states (including the District of Columbia) Minimum research commitment in 2013:$400 million

17. Examples From our Portfolio (CER) • Patient-Centered Support for Contraceptive Decision Making Project Detail • Long Term Outcomes of Lumbar Epidural Steroid Injections for Spinal Stenosis Project Detail • Improving Patient Decisions about Bariatric Surgery Project Detail • Evaluation of a Patient-Centered Risk Stratification Method for Improving Primary Care for Back Pain Project Detail • Effect of Glucose Monitoring on Patient and Provider Outcomes in Non-Iinsulin Treated Diabetes Project Detail • Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in PCI Project Detail

18. Examples From our Portfolio (System( • Using Telehealth to Deliver Developmental, Behavioral, and Mental Health Services in Primary Care Settings for Children in Underserved AreasProject Detail • The Family VOICE Study: A Randomized Trial of Family Navigator Services Versus Usual Care for Young Children Treated with Antipsychotic MedicationProject Detail • Improving Childhood Obesity Outcomes: Testing Best Practices of Positive OutliersProject Detail • Changing the Healthcare Delivery Model: A Community Health Worker/Mobile Chronic Care Team Strategy Project Detail • Project: PATient Navigator to rEduce Readmissions (PArTNER) Project Detail • A Patient-Centered Approach to Successful Community Transition After Catastrophic Injury Project Detail

19. Examples From our Portfolio (Other) • CT Radiation Dose Registry to Ensure a Patient-Centered Approach for Imaging Project Detail • Extension Connection: Advancing Dementia Care for Rural and Hispanic Populations Project Detail • Effectiveness of DECIDE in Patient-Provider Communication, Therapeutic Alliance & Care Continuation Project Detail • Reducing Disparities with Literacy-Adapted Psychosocial Treatments for Chronic Pain: A Comparative Trial Project Detail • Peer Health Navigation: Reducing Disparities in Health Outcomes for the Seriously Mentally Ill Project Detail • Patient Priorities and Community Context: Navigation for Disadvantaged Women with Depression Project Detail • Improving Health Outcomes among Native Americans with Diabetes and Cardiovascular Disease Project Detail • Statistical Methods for Missing Data in Large Observational Studies Project Detail

20. National Patient-Centered Clinical Research Network • Up to 8 Clinical Data Research Networks (CDRNs), which are system-based networks (such as hospital systems) that have the potential to become an ideal electronic network, without structural impediments. • Up to 18 Patient-Powered Research Networks (PPRNs), which are groups of patients interested in forming a research network and in participating in research. • A Coordinating Center which will provide technical and logistical assistance under the direction of the Steering Committee and PCORI Staff.