Saying No Isn't NICE – The Travails of Britain's National Institute for Health and Clinical Excellence

Britain's National Institute for Health and Clinical Excellence (NICE) is an independent, government-funded organization that advises the British National Health Service (NHS) in three areas of health: public health, health technologies, and clinical practice. NICE develops various forms of guidance using the best available evidence and comparative effectiveness research.

NICE has been criticized for the slow release of its appraisals, delaying the availability of some treatments that it eventually recommends. Some view NICE as an unkind rationing agency, while others see it as an impartial messenger of the need to set priorities in health care.

Comparative effectiveness is a current and relevant topic in health care financing in the U.S. and was included at part of the President-elect's health care platform. Understanding how this process has worked in the U.K. is important to considering policy approaches and options in the US.

Health Care Opinion Leaders' Views on Payment System Reform

The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey asked a group experts and opinion leaders in healthcare about health care payment system reform. The results revealed a fundamental dissatisfaction with the way health care is paid for in the United States.

Two-thirds of those surveyed felt the fee-for-service system was not effective at encouraging high quality and efficient care, and three-quarters favored a move toward bundled per-patient payment. Opinion leaders also supported Medicare negotiation of pharmaceutical prices and competitive bidding for durable medical equipment, and a majority supported the creation of a board to make Medicare payment and benefit decisions, subject to congressional guidelines.

This article highlights the belief of many that efficient, high-value care cannot be achieved without fundamental provider payment and delivery reform.

Insurers Hire Radiology Police to Vet Scanning

The number of computed tomography (CT) scans and magnetic resonance imaging (MRIs) increased 43 percent in five years to a combined 96.2 million procedures in 2007. Rising costs have prompted many insurers to employ outside firms to manage radiology benefits.

The goal of radiology benefit managers (RBMs) is to reduce costs by helping to ensure that physicians order high-tech procedures only when medically necessary, but evidence of inappropriate use continues. According to the article, the three big RBMs say they generally give ready approval to 70 percent or more of doctors' requests for scans after receiving some basic information from the physician's office, and authorize additional scans after in-depth conversations with physicians. The article also highlights the risk of high doses of radiation, particularly in the case of CT scans.

Understanding the trend associated with radiology benefit management is relevant to our work on the Radiology project, as well as smart benefit design.

Imaging Boom: Expanded Use of Imaging Technology and the Challenge of Measuring Value

As noted in the WSJ article above, the availability of CT and MRI scanning has grown rapidly but the value of that increased availability is not clear. This study documents the relationship between CT and MRI availability and use, and considers potentially important sources of benefits. The authors discuss key questions that need to be addressed if value is to be well understood. For example, expanded imaging may be valuable because it provides quicker access to more precise diagnostic information, although evidence for improved health outcomes is limited. Because this may be a common situation, it is important to understand how to quantify the non-health-outcome benefits of imaging.

The Case of CT Angiography: How Americans View and Embrace New Technology

This report highlights the controversy surrounding the use of CT angiography (CTA). Previous studies have shown mixed results on the effectiveness of this technology for diagnosing heart disease; this report states that there is no conclusive evidence that CTA leads to treatment that saves lives. The article includes an overview of benefits versus costs and a discussion of constraints versus innovation. Critics of constraints on new technologies say constraints could stifle ongoing innovation.

By last year, Medicare officials had become concerned about CT angiography's rapid adoption "despite the lack of clinical evidence to demonstrate improved patient health outcomes." CMS went on to propose rules that would limit the group of patients who could receive paid CTA, and went onto propose another condition: patients who received the exam would have to be enrolled in clinical trials aimed at determining if the procedure was more effective than cardiac catheterization.

This report is an important one as it conveys both the rules CMS proposed to limit CTAs, and the responses of physicians and industry that resulted in the continuation of CT angiography as a covered Medicare benefit and broadly available for symptomatic intermediate risk patients.

Wellness Programs

Chronic diseases contribute to rising healthcare costs, falling productivity, and work force shortages amid an aging population. Yet many of the health risks associated with chronic disease - including obesity, smoking, and lack of exercise — are at least partially preventable.

With the importance of controlling health risks becoming ever more evident, effective wellness programs are growing more crucial for healthcare organizations and employers alike. This issue brief shows that while the return on investment varies from organization to organization, wellness initiatives have demonstrated consistently favorable returns, including a reduction in sick leave absenteeism, workers compensation, and disability management claims costs; and a median return on investment of roughly 3 to 1, meaning that employers save approximately $3 for every $1 spent on wellness programs.