This article focuses on the overarching question: how can we use existing data to develop the capacity to improve the evidence base on personalized medicine technologies and particularly regarding their utilization and clinical utility? We focus on data from health payers who are key stakeholders in capacity building, as they need data to guide decisions and they develop data as part of operations. Broadly defined, health payers include insurance carriers, third party payers, health-plan sponsors and organized delivery systems. Data from health payers have not yet been widely used to assess personalized medicine. Now, with an increasing number of personalized technologies covered and reimbursed by health payers, and an increasing number of emerging technologies that will require policy decisions, there is a great opportunity to develop the evidence base using payer data and by engaging with these stakeholders. Here, we describe data that are available from, and are being developed by, health payers and assess how these data can be further developed to increase the capacity for future research, using three examples. The examples suggest that payer data can be used to examine clinical utility and approaches can be developed that simultaneously address the characteristics of personalized medicine, real world data and organizations. These examples can now help us to elucidate how to best examine clinical utility in actual practice and build evaluation approaches that can be applied to future technologies.
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http://dx.doi.org/10.2217/pme.10.36 | DOI Listing |
Surg Obes Relat Dis
January 2025
Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Division of Health Services Policy and Practice, Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, New York.
Background: Earlier evidence indicated that metabolic and bariatric surgery (MBS) may adversely affect neonatal outcomes among patients conceiving soon after MBS, but recent studies demonstrated conflicting results, especially for new surgical techniques.
Objectives: The aim of this study was to assess the effects of MBS types and surgery to birth interval on maternal, birth, and nonbirth outcomes in women with severe obesity.
Setting: New York State's all-payer hospital discharge database (2008-2019).
J Clin Lipidol
December 2024
University of North Carolina at Chapel Hill, UNC Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC 27599, USA.
Background: Widespread familial hypercholesterolemia screening requires a large upfront economic investment, but the health benefits and cost savings of cardiovascular disease prevention directed by screening occur over many years.
Objective: We evaluated the cost-effectiveness of population genetic screening for familial hypercholesterolemia compared to cascade testing to US payers while accounting for patient insurance switching between commercial and Medicare insurance.
Methods: We developed a hybrid decision-tree Markov model to assess genetic screening in 20-year-old adults over a lifetime horizon in which cohort members transitioned between commercial payers representing three commercial plans and Medicare.
Diseases
January 2025
Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK.
Background/objectives: For healthcare institutions developing a robotic programme, delivering value for patients, clinicians, and payers is key. However, the impact on the surgeon, training pathways, and logistics are often overlooked. We conducted a study on the impact of robotic surgery on surgeons, access to robotic surgical training, and factors associated with developing a successful robotic programme.
View Article and Find Full Text PDFAm J Manag Care
January 2025
Department of Population Health Sciences, Weill Cornell Medicine, 575 Lexington Ave, 6th Floor, New York, NY 10022. Email:
Objectives: Medicaid is the largest payer of mental health (MH) services in the US, and more than 80% of its enrollees are covered by Medicaid managed care (MMC). States are required to establish quantitative network adequacy standards (NAS) to regulate MMC plans' MH care access. We examined the association between quantitative NAS and MH care access among Medicaid-enrolled adults and among those with MH conditions.
View Article and Find Full Text PDFJNCI Cancer Spectr
January 2025
Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
Background: Early palliative care is associated with better outcomes for patients with advanced-stage cancers. Using a novel data linkage, we assessed outpatient palliative care use before death and its association with end-of-life care intensity and variation across eight provider networks.
Methods: We linked Massachusetts Cancer Registry and the All-Payer Claims Database for individuals with commercial insurance, Medicaid or Medicare Advantage diagnosed with colorectal, lung, prostate, and breast cancers from 2010 through 2013 who died by December 31, 2014.
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