Guidelines and Value-Based Decision Making: An Evolving Role for Payers.
Payers use evidence-based guidelines to promote effective health diagnoses and treatments for their members and to ensure that members are not subject to harmful or wasteful care. Payer guidelines inform coverage, but the content of these guidelines relies on the same evidentiary base as clinical treatment guidelines. Recent strategies to foster value through benefit design and alternative reimbursement methodologies illustrate emerging applications for evidence-based guidelines. The current focus on cost effectiveness within health technology assessment, comparative effectiveness research in collaboration with payers, and transparency around payer evidence assessment could better align payers' interests in evidence-based care with those of other stakeholders. The move to value in health care will depend upon credible clinical evidence to enable informed decision making.
senior medical director, Medical and Reimbursement Policy, Blue Cross and Blue Shield of North Carolina; assistant consulting professor, School of Medicine, Duke University, Durham, North Carolina Janet.McCauley@bcbsnc.com.
Janet L
JL
McCauley
D003362:Cost-Benefit Analysis; D003659:Decision Making, Organizational; D019317:Evidence-Based Medicine; D006801:Humans; D007348:Insurance, Health; D017410:Practice Guidelines as Topic; D012051:Reimbursement Mechanisms; D014481:United States; D062505:Value-Based Purchasing