Evidence-Based Policies Inform Healthcare Decisions, Reduce ...

Ev idence-B a s e d Pol ic ie s I n for m
He a lt hc a re Decision s ,
Re duce Prac t ice Va r iabi l it y
INDUSTRY PULSE FROM THE HEALTHCARE INTELLIGENCE NETWORK TM
Thomas M. Kosloff,
D.C., is the Associate
Medical Director at
OptumHealth Care
Solutions, Inc. Dr.
Kosloff has extensive
experience in private
practice and utilization
management. He
currently oversees
clinical policy
development and
related consumer
resources created
by OptumHealth
for Physical Health
services. In addition, Dr.
Kosloff provides subject
matter expertise for
the UnitedHealthcare®
Medical Technology
Assessment Committee.
He also has been
a participant on a
multidisciplinary
professional consensus
guideline panel. Dr.
Kosloff graduated from
the New York College
of Chiropractic and
completed postgraduate
studies in orthopedics
at New York
Chiropractic College
and neurology at Logan
College of Chiropractic.
With a strong emphasis on high-value
healthcare and the growing demand for
comparative effectiveness assessments of
healthcare services led by the Agency for
Healthcare Research and Quality and
further encouraged by the Patient Protection
and Affordable Care Act, healthcare
organizations are increasingly turning
to the use of evidence-based policies to
inform healthcare decisions, according to
Dr. Thomas M. Kosloff, Associate Medical
Director with OptumHealth Care Solutions,
Inc. (OptumHealth).
“With healthcare reform placing a higher
value on finite healthcare resources,
comparative effectiveness and evidencebased
healthcare policies will help us
determine how to spend these resources in
an efficacious way,” explained Dr. Kosloff.
These evidence-based healthcare policies
include a range of documents intended
to support the framework of health plan
member benefits described in certificates of
coverage and summary plan descriptions.
These may include medical, coverage
determination, utilization review, and
reimbursement policies or guidelines.
They constitute the criteria used to
determine medical necessity, proven/
unproven procedures, investigational
and experimental services, and payment
methodologies.
Evidence-informed policy is not simply an
extension of evidence-based medicine. It is
contextually different.[1] The incorporation
of research evidence in policy development
takes place within the framework of
contractual (benefit documents) and
regulatory requirements. Healthcare
policies are typically implemented across
large populations. They may vary from
evidence-based clinical practice due
to differences in local conditions (e.g.,
accessibility to certain services, differences
in cultural values, etc.).
These contextual differences
notwithstanding, the pursuit of evidencebased
policy is foundationally aligned with
evidence-based practice. Both are founded
upon the premise that healthcare decisions
should be informed by the best available
evidence and should include a rational
analysis.[2]
Evidence-informed policy development can
facilitate cost-effective care, reduce practice
variability, support improved patient care/
outcomes, and ensure compliance with the
requirements of regulatory agencies and
accreditation bodies.[3-5] Encouraging the
use of high-value care, while discouraging
the use of low-value or unproven services,
will ultimately produce more consistency
within healthcare systems.
For example, the prevalence of
musculoskeletal conditions is high and the
treatment of these conditions consumes a
large percentage of healthcare resources.
Musculoskeletal disorders cost the United
States nearly $850 billion in 2004. [6] There
were more than 132 million physician visits
for musculoskeletal symptoms in 2006. [7]
There are consistent recommendations
based upon the qualitative appraisal of
clinical evidence for musculoskeletal
conditions. However, the issue is that
current practice does not appear to be
well-aligned with current clinical evidence.
OptumHealth, using clinical policies as a
foundation, works closely with providers

to try and close the gap between evidence and
practice. These efforts have resulted in reduced
practice variability, improved cost trends for
clients and favorable patient outcomes.
Evidence-Informed Policy Creation
The policies are created by looking at the
research evidence on a given topic. In
particular, OptumHealth forms the basis of
most of its policies by looking at systematic
reviews developed by experts who synthesize
a compilation of research into an interpretable
document.
Policies that are based upon systematic evidence
reviews have been shown to be associated
with better outcomes.[8] They allow for large
quantities of information (multiple clinical trials)
to be reduced into useable data that provide for
rational judgments in formulating guidelines
and positions concerning the use of certain
diagnostic tests and treatment strategies.
OptumHealth has developed 70 such policies
to guide healthcare decision-making. Of those
70 policies, 12 to 15 are high-impact, highutilization,
rigorous policies. One to two new
policies are developed each quarter.
“We’ve established a process that mirrors best
practices in clinical guideline development for
high-quality, clinical policies so that health plan
members receive their full benefit and health
plan clients have their resources allocated in a
way that presents value to the organization,” said
Dr. Kosloff.
“New policies can be proposed by various
stakeholders including clients, regulators,
compliance officers, clinical directors, support
clinicians and healthcare providers,” Dr. Kosloff
said.
“Once a policy topic has been proposed, its
necessity is typically established via a business
impact analysis. The analysis seeks to determine
if a policy is required by legislative mandate,
to support a current or planned utilization
management program, or recommended based
upon trends in service requests and/or claims
receipts,” explained Dr. Kosloff. “Policies that are
‘required’ receive high priority for development
and implementation. ‘Recommended’ policies
must meet a defined business purpose and have
been operationally mapped through a series of
systematic steps. These policy topics undergo
a structured decision analysis, which results
in their designation as a low, moderate or high
priority for development.”
Evidence-Informed Policy & Practice
Framework
The diagram below (Figure 1) provides a highlevel
conceptual model describing the alignment
of evidence-informed practice and policy. The
model utilizes both the quality and strength
of evidence as the foundation for making
judgments about clinical appropriateness.
Definitive conclusions about the efficacy of a
particular service for a target disorder requires
moderate/high quality evidence.[9] In both the
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Figure 1
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practice setting and with healthcare policy, as
the quality and strength of evidence become
weaker along this continuum, decisions about
clinical appropriateness become less confident
(supportable).
Policy Development
To create a policy guideline development team,
organizations have to adequately resource and
train staff to produce evidence-based policies.
Dr. Kosloff recommends prospective authors
work with experienced policy developers in the
process.
Policies are created by conducting a literature
search on the intervention being considered.
The policy staff then reviews the background
material and establishes key questions to be
answered around a particular population that
the policy is trying to address.
“The committee would look then at comparatives
for that intervention,” said Dr. Kosloff. “Is it
better than other treatments, or no treatment
or a placebo-treatment The intervention is
evaluated against patient-centered outcomes for
that treatment, such as quality of life, ability to
perform activities of daily living and symptom
severity.”
One of the most challenging aspects of the policy
development process is meeting regulatory and
compliance requirements, Dr. Kosloff warned.
Policies have to be developed in a fairly rapid
manner to meet the compliance requirements,
without sacrificing quality.
Another challenge in developing policies is to
make sure that the research findings can be
translated into language that is usable for health
plan members, said Dr. Kosloff.
OptumHealth has developed a definitive
logarithm to translate research evidence findings
into language that is compatible with member
benefit documents to address this challenge.
Once a policy is developed it does need to go
through a vetting process. OptumHealth has a
two-tier committee process that incorporates
academic experts and providers and brings in
the consumer perspective to ensure stakeholder
input.
The final step in policy development is
dissemination. OptumHealth uses a multi-modal
approach to communicate and disseminate
its policies. They are posted on its provider
portal, which is open-access, and summaries
are included in its quarterly newsletter.
OptumHealth also meets with professional
groups on a regular basis to present their policies
and seek feedback that is discipline-specific.
Monitoring and Evaluating Policy
“Once approved and implemented, a policy
requires ongoing monitoring and evaluation to
assess utility and impact,” said Dr. Kosloff.
Questions to Guide Policy
Monitoring and Evaluation
Is monitoring necessary
What should be measured
Should an impact evaluation
be conducted
How should the impact evaluation
be done
The term monitoring is commonly used to
describe the process of systematically collecting
data to inform policymakers, managers and
other stakeholders whether a new policy is
being implemented in accordance with their
expectations.
“Policies need to be audited to ensure that they
are adjudicated properly,” said Dr. Kosloff, “and
from a business model perspective, that they are
effectively achieving the anticipated outcome.”
Indicators are used for evaluative purposes
to judge, for example, if objectives are being
achieved. When the term impact evaluation
is used, this usually implies that there is a
specific attempt to try to determine whether the
observed changes in outcomes can be attributed
to a particular policy.[10]
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OptumHealth revises and updates one to two
policies per quarter. The policies are revised
through monitoring standing queries of
biomedical research on a particular topic.
Evidence-Based Policy Impacts
“One of the high-impact policies for
OptumHealth is a policy that looks at whether
continuing care is likely to be a benefit for
the patient for any particular service,” said
Dr. Kosloff. “This particular policy is used in
98 percent of all of its denials of services. For
clinicians making a judgement that continuing
care management is unlikely to benefit a patient
and may, in fact, interfere with the patient
accessing more effective care, the policy provides
a strong impact.”
“From a fiscal perspective, the policies can also
assist in helping claims to be adjudicated in the
manner intended,” Dr. Kosloff added.
As we move into a healthcare market that
emphasizes individuals making judgements
about their healthcare with health savings
accounts, evidence-informed policies that are
clearly communicated to clinicians and are easily
understood by patients, will support this patientbased
decision-making process and promote
high-value healthcare.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Black N. Evidence based policy: proceed with care. BMJ
2001; 323:275–2799
Sutcliffe S, Court J. Evidence-based policymaking:
What is it How does it work What relevance for
developing countries. Overseas Development Institute
Nov. 2005
Oxman AD, Grading the quality of evidence and
strength of recommendations. British Medical Journal
2004; 328:1490-1497
Reilly BM. The essence of EBM. British Medical Journal
2004; 329:991-992
Bronfort G, Haas M, Evans R, Leininger B, Triano J.
Effectiveness of manual therapies: the UK evidence
report. Chiropractic & Osteopathy 2010; 18:3
http://www.chiroandosteo.com/content/pdf/1746-
1340-18-3.pdf
United States Bone and Joint Decade: The Burden of
Musculoskeletal Diseases in the United
States. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2008.
National Ambulatory Medical Care Survey 1998-2006.
Data obtained from: U.S. Department of Health
and Human Services; Centers for Disease Control and
Prevention; National Center for Health Statistics.
Reilly BM. The essence of EBM. British Medical Journal
2004; 329:991-992
Sutcliffe S, Court J. Evidence-based policymaking:
What is it How does it work What relevance
for developing countries. Overseas Development
Institute Nov. 2005
Fretheim A, Oxman AD, Lavis JN, Lewin S. SUPPORT
tools for evidence-informed policymaking in health 18:
planning monitoring and evaluation of policies. Health
Research Policy and Systems 2009, 7(Suppl 1):S18
OptumHealth Contact Info:
Phone:(866) 427-6845
Email: engage@optumhealth.com
Web site: www.optumhealth.com
About OptumHealth
OptumHealth helps individuals navigate the healthcare system, finance their healthcare needs and achieve their health and wellbeing
goals. The company’s personalized health advocacy and engagement programs tap a unique combination of capabilities that
encompass public sector solutions, care solutions, behavioral solutions, specialty benefits and financial services. Serving nearly 60
million people, OptumHealth is one of the nation’s largest health and wellness businesses, and is a UnitedHealth Group® (NYSE: UNH)
company. More information about OptumHealth can be found at www.optumhealth.com.
©2010, Healthcare Intelligence Network®. All Rights Reserved.
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