Payer Decisions: Patient-Reported Outcomes, Clinical Outcome Assessments Seldom Used

Within the health care decision-making process, the impact of patient-reported outcomes (PRO) and clinical outcome assessments (COAs) on payers is often low, despite efforts to include the patient voice, according to recent survey results presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2019.

Oftentimes, both PROs and COAs measure a patient’s symptoms, mental state, and/or the effects of a disease or condition on patient function. More specifically, COAs are used to determine whether a drug had demonstrated treatment benefits.  

To better understand and evaluate trends within US managed care pharmacy and medical directors’ familiarity, interest, and utilization of COAs in decision making, a team of researchers, lead by Andrew Gaiser, PharmD, and colleagues, conducted an online survey. The survey responses were compared to a previous survey conducted in 2014, which assessed managed care pharmacy decision makers’ familiarity, interest, and utilization of PROs vs other types of COAs in decision making.

Dr Gaiser and colleagues received responses from 43 participants who covered more than 300 million lives across the United States. Notably, the respondents who completed the survey represented primarily regional plans.  

According to the findings, similar to the 2014 survey, 70% of the respondents reported being very or extremely familiar with PRO data. In the current survey, roughly 95% of the respondents responded affirmatively toward the credibility of clinician-reported outcomes compared to any other COA, and PROs had the lowest credibility rating. Further, more respondents confirmed that clinician-reported outcomes are the most impactful on tier placement and utilization management. This also was reported to have the highest overall value.

“Current respondents rated PRO endpoints within clinical trials most relevant in psychiatry (79%) and least relevant in immunology (56%),” Dr Gaiser and colleagues explained. “Respondents also indicated that although they infrequently use PROs in managed care activities, they are most often used to improve patient care (60%) through disease management programs and quality metrics (both 54%).” 

The researchers noted that 72% of respondents indicated that they never or seldom use PROs to determine product access and/or coverage.  

“Despite increased efforts to include the patient voice in health care decision making, the impact of PROs and other COAs on payer decision making within the US is low,” Dr Gaiser and colleagues concluded. “There is a need for further efforts to better define the role of COAs, specifically PROs, in payer decision making so as to increase utilization.” —Julie Gould