Legislature Considers Evidence-Based Approach for Insurance Reform

The insurance commissioner would have the authority to prohibit coverage that doesn’t meet the guidelances established by the Health Evidence Review Commission

January 30, 2013 -- Dr. John McAnulty, a cardiologist at Legacy Health System, knows all too well that medicine can’t sort out every last detail – particularly when it comes to evidence-based care.

That’s why he supports a legislative proposal allowing the Oregon Insurance Division to initiate a pilot program using the protocols developed by the Health Evidence Review Commission.

Created in 2011 after passage of House Bill 2100, that commission is charged with coming up with evidence-based findings – known as guidances -- for providers, consumers and healthcare purchasers, including the state’s Medicaid plan.

Thus far, it’s approved 18 medical protocols, such as treatment of lower back pain and is currently reviewing treatments for cervical cancer screening and attention deficit hyperactivity disorder. 

McAnulty, who’s met with Governor Kitzhaber and Insurance Commissioner Lou Savage, realizes that physicians often fall short of focusing on what the evidence shows when caring for their patients. “We’re getting better doing things for which such information is available, but we’ve been slow to react, and that slowness has turned into a disadvantage to many patients,” he said.

Evidence-based care can also lead to lower insurance costs for consumers and employers, he said. “If the money saved by not paying for certain treatments just goes to insurance companies, it wouldn’t be a very worthy goal, but if it can be translated into reducing premium costs, I’d favor that.”

Larry Kirsch, a health economist and managing partner of IMR Health Economics in Portland, has been the driving force behind this concept. He says it’s time for private health insurers to heed the call and start paying for medical procedures that can be backed up with scientific evidence.

Kirsch drafted the legislation working in consultation with McAnulty, Dr. Michael Savage, an internist at the Broadway Clinic, and Amy Johnson, a local attorney who was the first Public Insurance Counsel appointed in Texas to represent consumers in insurance matters

Several Democratic legislators have agreed to sponsor House Bill 2135 and its accompanying Senate Bill 122, including Rep. Mitch Greenlick and Sens. Elizabeth Steiner-Hayward and Chip Shields, therefore the bill will be introduced in the House and Senate healthcare committees.

It gives the Insurance Division the authority to prohibit health plans from providing coverage that doesn’t meet the guidances developed by the Health Evidence Review Commission – and also requires them to meet those standards – starting out with a pilot project.

Not only would this strategy reduce medical costs, it would also improve the quality of healthcare, Kirsch said. “We need to begin shifting from procedures which have no significant scientific base to those that have very strong scientific evidence. It has big cost cutting implications as well.

“In reality, when you look at actual utilization, doctors are still going out and doing whatever they want to do because they learned it that way in medical school,” he added. “ This is an attempt to try using the regulatory system because professional education hasn’t worked as fast as people think it should.”

As an example, Kirsch pointed to a recent study conducted by U.S. Oncology and Aetna which demonstrated that treating non-small cell lung cancer patients with evidence-based care resulted in an average cost savings of 35 percent over 12 months without affecting health outcomes.

“Applying a 35 percent cost saving to the prevalence and cost of treating non-small cell lung cancer in the Thomson Reuters MarketScan Research Database, would result in an annual savings of $1.14 billion for the under 65 population alone,” he added.

The University of Michigan Medical School has also been working collaboratively for several years with the hospitals, physician organizations and Blue Cross of Michigan to develop such guidelines. Its research found that implanting stents in coronary arteries was beneficial to certain patients while other patients were more effectively treated with certain drugs.

“Rather than fiddling around at the margins to bend the cost curve, this can be an innovative strategy not only for cost containment but also quality improvement,” Kirsch said. “Given Governor Kitzhaber’s commitment to evidence-based medicine, we expect him to be very supportive of trying to move this along.”


To learn more about the study of non-small-cell lung cancer cited by Larry Kirsch, click here.

M. Neubauer, J. R. Hoverman, M. Kolodziej, L. Reisman, S. Gruschkus, S. Hoang, A. Alva, M. McArthur, M.

Forsyth, T. Rothermel, R. Beveridge; “Cost Effectiveness of Evidence-Based Treatment Guidelines for the

Treatment of Non–Small-Cell Lung Cancer in the Community Setting”; JOP Jan 2010: 12-18.

Image for this story by Darny Zsoka (public domain) via Wikimedia Commons.

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