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Value and coverage: How reimbursement decisions impact innovations needed to improve health


The healthcare system in the United States is ever-evolving and complex. There are tremendous pressures now to reduce the nearly $3 trillion we spend on healthcare each year without compromising the quality of care and outcomes for patients. The notion of value (that is, receiving high quality care at lower costs) is fundamental to reforming the healthcare system away from the current fee-for-service payment models that reward providers for giving more care rather than better care.

As we move towards a system that champions value, there is a need to define it for specific conditions and treatments and identify metrics that can be used to make these determinations. During the Value and Coverage: How reimbursement decisions impact innovations needed to improve health Webinar on April 22 moderated by FasterCures Executive Director Margaret Anderson, Dean Rosen, president and CEO of Breakaway Policy Strategies, and Brian Rosen, senior vice president of the Leukemia and Lymphoma Society (LLS), shared their perspectives on how healthcare stakeholders (such as patients, providers, government and private payers, researchers) can foster an insurance reimbursement environment that supports medical innovations and provides patients with access to new and promising therapies.

Dean outlined the first three of six level-setting issue briefs developed by Breakaway for FasterCures. These papers provide a landscape overview of the major issues that impact reimbursement and coverage decisions today.

  • A Closer Look at Health Plan Coverage Policies and Approaches: Although most private plan coverage policies are proprietary, this paper summarizes information that is publicly available on how medical coverage decisions are made.  
  • A Closer Look at Alternative Payment Models (APM): This paper outlines four common APMs that have been adopted by both private and government payers — accountable care organizations, bundled payments, pay-for-performance, and patient-centered medical homes.
  • A Closer Look at Evidence-Based Performance Measurement: This paper discusses the importance of defining quality and quality metrics as healthcare systems increasingly reward quality.

Representing a patient advocacy foundation’s perspective, Brian spoke to how LLS convened stakeholders to address holistically the barriers and challenges associated with bringing innovative treatments to blood cancer patients. For LLS, he said, it is as important to find a cure for blood cancer as it is to ensure sustainable access to the treatments. Brian described the process of bringing together a group of patients, providers, researchers, payer, manufacturers, health economists and sociologists to discuss blood cancer treatment issues and identify payment models that may make innovative treatments affordable to patients. The group ultimately recommended a study to assess how cost and value issues impact patient and provider decisions.

Both speakers agreed that aligning and understanding stakeholder, particularly patients, views are critical to developing a value-based reimbursement system that fosters innovation. By strengthening the role of patients in determining quality metrics and coverage decisions, we can help make reforms to the healthcare system that have a positive impact on the lives of patients.  

Relevant resources:

“The squeeze is on,” stated a very resolute Mary Dwight of the Cystic Fibrosis Foundation, as she introduced the topic of value and coverage at one of the closing day sessions of the Milken Institute’s Global Conference. Dwight moderated the five-member panel’s discussion of a subject that spans medical innovation, health care reform, new models for delivering and financing health care, and personal choice and access to products and services. The panel included experts in patient advocacy, industry innovation, payers, and policy.