November 26, 2010

Sleep apnea, comparative effectiveness and the future

The need for comparative effectiveness research follows from a recognition that we, as a country, don't have unlimited resources to expend on the delivery of healthcare; particularly as it relates to medical devices.

It makes sense for healthcare payors to pay for what works and not what doesn't. That said, there is very little incentive for innovation if the hurdle of effectiveness is so high that medical device manufacturers are reluctant to spend the money in research and development.

For those using Positive Airway Pressure therapy to treat obstructive sleep apnea, the question of comparative effectiveness can be an concern, especially when there is innovative technology available to make treatment more effective or more comfortable.

Recently I attended a breakfast meeting hosted by the publishers of Health Affairs. Their October issue of the publication was dedicated to the question of comparative effectiveness. While the entire issue is worth reviewing there was one article of particular interest to me.

Steven Pearson and Peter Bach considered a way to incorporate comparative effectiveness into the reimbursement scheme for Medicare. Quoting from the article: "Upon making a new coverage decision, Medicare would assign the service (added - heath care item) to one of three payment categories based on the evidence of comparative clinical effectiveness. After an initial three-year period, if services with insufficient evidence do not provide additional evidence demonstrating superior clinical effectiveness, payment would drop to reference pricing levels."

This strategy allows for companies introducing new technology to get three years of "dynamic pricing" and to allow for the manufacturers and clinicians to perform research to demonstrate superior effectiveness of existing therapies.

The recently published draft comparative effectiveness review on the diagnosis and treatment of obstructive sleep apnea in adults did not find compelling research to show the superiority of other PAP therapy over traditional CPAP.

How this report is used could make it harder for device manufacturers to realize a higher rate of reimbursement for more sophisticated technology. But using the scheme proposed by Pearson and Bach there could be some additional benefit pending the clinical outcome data to justify a high reimbursement.

Dr. Berwick, if you are listening... I think incorporating comparative effectiveness model proposed in Health Affairs into what Medicare will reimburse and at what rate makes a lot of sense, particularly when it comes to therapies (PAP and OAT)for the treatment of Obstructive Sleep Apnea.


Snoring Elephant said...

I agree fully with your blog.

It will be interesting on the amount spent on re-tritration as opposed to the auto PAP.

Anonymous said...

Problem is that cochrane reviews of technological advances associated with PAP devices show very little effect. It can be difficult to show an effect for any one technological change, relative to the overall effect of PAP therapy. Not saying that everyone should be on fixed pressure, but that technological advances alone are not a silver bullet for PAP therapy. It simply takes work on the parts of both patient and provider, and the real issue is the lack of reimbursement for the required work (ie, provider time) that is necessary once someones starts on therapy.