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

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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 The Healthcare Intelligence Network is the premier advisory service for executives seeking high-quality strategic information on the business of healthcare. Figure 1 2
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] The Healthcare Intelligence Network is the premier advisory service for executives seeking high-quality strategic information on the business of healthcare. 3
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