Abstract P4-15-02: Lessons learned: Implementing the WISDOM study using private payors to cover study services and generate evidence

Background: Generating real world evidence in support of value-based healthcare solutions has traditionally been difficult due to the nature of funding and reimbursement mechanisms. Pragmatic, comparative effectiveness studies need additional funding to cover study costs, and systems are not in place to incorporate evidence generation into improving health outcomes. In 2005, the Centers for Medicare and Medicaid Services (CMS) identified the need to broaden access to innovative therapies and practices, and implemented a Coverage with Evidence Development (CED) model. This model has not been adapted by private payers.

Methods: The WISDOM (Women Informed to Screen Depending on Measures of risk) Study in collaboration with the Patient-Centered Outcomes Research Institute (PCORI), addressed this challenge by co-developing a private payer coverage with evidence progression (CEP) model, based upon Medicare’s CED policy. Since the study began in 2016, numerous payers cover the WISDOM Study using CEP, including private, Medi-Cal, and self-insured employer groups, across six states (California, Illinois, Iowa, New Jersey, North Dakota and South Dakota). The payers helped cover study services used for risk assessment and high-risk counseling in the WISDOM Study.

Results: The first barrier was the payer’s fiscal concerns over adopting CEP, which was overcome by establishing the case for evidence generation as a route to better outcomes, cost savings and overall healthcare value. The second barrier was that health insurance companies may only control benefits for a fraction of their members. To overcome this barrier, WISDOM Study Investigators extended CEP to self-insured employers, who have been enthusiastic proponents in covering and recruiting participants. In implementing CEP, a third significant barrier was billing for individual services on a national scale. In response, WISDOM investigators established a scalable and replicable billing infrastructure for pre-approving and submitting claims for study services.

Discussion: The WISDOM Study is a pragmatic, comparative effectiveness trial that provides a framework for future research studies to adopt and build upon. For CEP to be scalable, an established simple mechanism is essential. For every limitation, we have identified important lessons that have been learned during the study’s implementation to address what started as insurmountable barriers and ended as a critical demonstration of feasibility.

Conclusion: These obstacles may inform subsequent implementations of coverage for evidence generation purposes as a means to promote value-based improvements in care.

Citation Format: Yash S Huilgol, Kenneth Wimmer, Erick Lin, Marcus Thygeson, Allison S Fiscalini, Karyn DiGiorgio, David Kraus, Lisa M Latts, Laura Tauber, Trent T Haywood, Athena Breast Health Network Investigators and Advocate Partners, Laura J Esserman. Lessons learned: Implementing the WISDOM study using private payors to cover study services and generate evidence [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-15-02.

Abstract P4-12-03: Tailoring screening to individual risk decreases the cost and improves the value of screening

Introduction:

Health care spending rose from 5% to 17.8% of GDP between 1960 and 2015. Clinicians and researchers must engage in increasing health care value – better outcomes at less cost. Personalized screening is one such opportunity. The Patient Centered Outcomes Research Institute recently funded WISDOM (Women Informed to Screen Depending On Measures of risk), a randomized trial to tests the safety and efficacy of basing starting age, stopping age, frequency and modality of breast cancer screening on individual risk (Clinical Trials Identifier NCT02620852). The personalized arm of WISDOM integrates genetic testing into the risk algorithm. Funding for the clinical services of WISDOM (genetic test, risk assessment, high-risk counseling) are expected to be covered ( health plans, insurers). Risk determines the frequency, time to initiate screening and drives cost of downstream screening services. The cost of genetic testing is now less than $250, comparable to a mammogram. The WISDOM study model brings payers, policy makers, provider, technology, and advocate partners together to generate evidence to see if risk based screening is as safe, less morbid, preferred by women, promotes prevention, and has greater health care value. Health plans need to know the value proposition, thus we evaluated financial implications of coverage for risk-based screening.

Methods:

A model was developed to compare costs and benefits of risk-based vs. current screening practices from the perspective of a health plan. Modeled cohorts resembled a screening population with risk determining screening interval for the risk-based model, and average time between mammograms determining the interval for the model of current screening practices. Model parameters were gathered from published literature, national databases, early findings from WISDOM and health plan claims data. Sensitivity analysis was performed on all parameters, including costs of clinical services, screening rates, and health plan turnover. The clinical services specific to WISDOM use a fixed-fee schedule, and not varied in the model. All other costs were conservative, based on Medicare rates and published literature.

Results:

We estimated that over five years, risk-based screening is at worst cost neutral with potential for savings of up to $215 per participant. Based on current trial enrollment, we estimated that 30 per 1,000 health plan enrollees would join, resulting in an upfront cost of $6,000 for WISDOM-specific services, primarily the genetic test, and $600 in ongoing costs after Year 1. However, the health plan would save on mammogram and work up costs as participants would receive an average of 2-3 fewer mammograms over five years. Savings are sensitive to the age of participants, cost of mammograms, and savings increase over time. Per participant, five-year savings of $300 and $35 for those aged 40-49 and 65-74 respectively, and increased costs of $30 for those aged 50-64. Overall, an upfront investment of $6,000 per 1,000 health plan enrollees (30 participants) yields $3,800 in five-year savings.

Conclusion:

Personalized screening could provide cost savings and has the potential to increase health care value. Enrollment in the Wisdom study is ongoing and results will be reported in 5 years.

Citation Format: Wimmer K, Stover Fiscalini A, Eklund M, DiGiorgio K, Naeim A, Athena and Wisdom Investigators, Esserman L. Tailoring screening to individual risk decreases the cost and improves the value of screening [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-12-03.