State of Washington, Health Care Authority

1
State of Washington, Health Care Authority

• Steve Hill, Administrator
• Leah Hole-Curry HTA Program Director

September 2008
2
WA STATE HEALTH CARE AUTHORITY

• Health Care Authority Environment
• Approximately 300 employee Cabinet level agency
• Administers WA public employee and retiree
  benefits and state low income health coverage
• 3 Billion annual health care expenditures
• 450,000 beneficiaries
• Approximately 200,000 self-insured
• Three insured plans serve remaining 250,000
• HCA Website http//www.hca.wa.gov

3
Governor Gregoires Health Priorities

• Increase Access to health care coverage
• Create a Sustainable, affordable and quality
  health care system
• Centralized, collaborative, evidenced based
  system to set priorities and determine what the
  State will pay for.
• Effectively manage the High Opportunity
  populations insured or sponsored by the State
  5-50 population
• Promote the transparency of health plan and
  provider performance.
• Prevention and Wellness for State Employees and
  Beneficiaries
• Encourage technology improvements in
  patient/provider information
• Improve the health of people in WA

4
HEALTH CARE AUTHORITY INITIATIVES

• Health Care Authority Efforts towards Governor
  initiatives on a Sustainable, affordable and
  quality health care system
• HTA Program Prescription Drug Program Patient
  Decision Aid Demonstration
• High priority conditions health coaching and
  care management
• Puget Sound Health Alliance Collaboration
• Health Risk Assessments and Wellness Campaign
• Health Record Banking project and IT grants

5
HTA Products / Benefits
Why EBP
Pay for What Works Better Information is Better
health

• Transparency
• publish process, criteria, reports
• committee decisions in open, public meeting
• Evidence Reports
• Formal, systematic process to identify, review,
  and cover appropriate health care technologies
• Coverage decisions
• Independent committee of health care providers
• Rely primarily on evidence report
• Consistent across state health care purchasing
  agencies
• Is it safe?
• Is it effective?
• Does it provide value (improve health outcome)?

6
New Health Purchasing Focus Hierarchy of
Evidence

• Best Meta-analysis of large randomized
  head-to-head trials.
• Large, well-designed head-to head randomized
  controlled clinical trials (RCT)
• Long-term studies, real clinical endpoints
• Well accepted intermediates
• Poorly accepted intermediates
• Smaller RCTs, or separate, placebo-controlled
  trials
• Well-designed observational studies, e.g.,
  cohort studies, case-control studies
• Safety data without efficacy studies
• Case series, anecdotes
• Least Expert opinion, non-evidence-based expert
  panel reports, and other documents with no direct
  clinical evidence

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Evidence in Health Care Decision Making

• Level 3 What would I recommend to the state or
  nation?
• Must be based on rigorous assessment of the
  scientific evidence.
• Affects hundreds of thousands, even millions of
  people.
• Level 2 What would I recommend to my
  patient/client?
• Influenced by prior experience, but the
  scientific evidence may play a greater role.
• Affects possibly hundreds of people.
• Level 1 Would you have this done for yourself
  or for someone else in your immediate family?
• Influenced by ones personal experience with the
  disease and capacity to deal with risk.
• Affects few people.
• Used with Permission from Dr. Mark Helfand,
  OHSU

8
HTA Program Elements Four Keys

• HCA Administrator Selects Technology
• Nominate, Review, Public Input, Prioritize
• Vendor Produce Technology Assessment Report
• Key Questions and Work Plan, Draft, Comments,
  Finalize
• Clinical Committee makes Coverage Determination
• Review report, Public hearing
• Agencies Implement Decision
• Implements within current process unless
  statutory conflict

Semi-annual
2-8 Months
Meet Quarterly
9
HTA Program Outcome

• Technologies Selected
• Upright MRI
• Pediatric Bariatric Surgery
• Lumbar Fusion for DDD
• Discography for DDD
• CT Colonography
• Intrathecal Pumps for pain
• Knee Arthroscopy for OA
• Artificial Discs
• Cardiac Stent
• CTA for cardiac care

• Status
• Not Covered
• Conditional Coverage
• Conditional Coverage
• Not Covered
• Not Covered
• Not Covered
• Not Covered
• Draft Report Published
• Report Underway
• Report Underway

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HTA Challenges

• Resource (time and cost) Intensive
• Systematic reviews are time consuming and
  expensive
• Replication of current analysis
• Multiple comment periods and open process
  requirements
• Change in Policy Decision making Model
• Proof vs. Persuasion
• Integrate Industry/Provider/Patient view into
  evidence
• Policy Requires Additional Considerations
• Alternatives, criticality and burden of condition
  
• Information Gap
• Low quality of information for complex/controversi
  al issues