Dr Jennifer Graff on How Payers Make Decisions

Jennifer Graff, PharmD, vice president of comparative effectiveness research at the National Pharmaceutical Council, discusses where payers receive their information and how it is used to make decisions about coverage and reimbursement.

Transcript (slightly modified)

What forms of evidence are considered optimal in order to make informed decisions related to coverage and reimbursement?

Payers use a wide variety of information to make coverage and reimbursement decisions. They use the best available information to try to determine safety, effectiveness, which treatments work best for which patients, and how a treatment compares to other treatment alternatives. This best available evidence could take many forms and could include FDA information, manufacturer supported information, clinical trials, real-world evidence, and cost-effectiveness. We know this by peeling back the onion to try to understand not only what payers say they do and utilize, but also looking at P&T monographs or looking at medical coverage policies to understand what types of evidence they cite. It’s a wide variety of types of information and often very desperate.

The challenges that many payers have is that what they would optimally like to have may not always work out in the real world. There’re timing issues and they have to make a decision within the first 90 days that a product is available, so all the information about how a treatment works in the real world isn’t often available. They have staff and resource issues to try to evaluate all of the different types of information and there are also issues about what information can be available and when. So, what payers are looking for, really is optimally a wide variety of information. What is used can change from payer to payer, and may not always reflect the real-world.