Two points of view. One solution.

Highmark Health applies the provider and the payer perspective to new medical technologies

Matthew Tucker

Supply chain executives and their contracting teams work hard to make new technology decisions that make sense for patients and their families, clinicians, and the health system’s CFO. The tension between cost and quality is ever present.

As both provider and payer, Pittsburgh-based Highmark Health believes it is in a unique position to resolve – or at least reduce – that tension.

Highmark’s Allegheny Health Network provides healthcare delivery, research, medical education, and wellness services through an integrated delivery network of eight hospitals and more than 2,300 staff physicians. Meanwhile, Highmark Inc. and its affiliates operate health insurance plans in Pennsylvania, Delaware, and West Virginia, which serve more than 4.4 million members, and hundreds of thousands of additional individuals through its BlueCardprogram.

In 2015, Highmark Health created its VITAL Innovation Platform, which analyzes clinical and claims data to test the viability of FDA-approved technologies. Last fall, VITAL announced it would test Moving Analytics’ MOVN virtual cardiac rehabilitation solution for delivering cardiac rehab remotely to patients with heart disease.

“Highmark Health is in a unique position as a payer and clinician-led integrated system [to] make decisions with the best interests of the patient in mind, not thinking in a one-sided fashion,” says VITAL’s director of strategy, Matthew Tucker. “That allows us to look for the most innovative technologies to achieve a win-win for both improving patient’s health and better controlling costs.”

The Journal of Healthcare Contracting asked Tucker to talk about VITAL and the broader question facing not only supply chain executives, but developers of new medical technologies as well: How do we balance cost and quality?

Journal of Healthcare Contracting: Talk about the challenges facing startup companies as they work to gain a market for their innovations.

Matthew Tucker: Innovative products and solutions often face post-approval challenges with adoption due to lack of clinical and economic evidence compelling enough to open access and availability, thereby delaying the impact they can have on patient care.

Increasingly, payers and health systems across the nation feel that evidence generated for approval or clearance by the FDA doesn’t give a complete picture of the potential impact a product could have on clinical care or cost reductions. To answer these questions, Highmark Health’s VITAL platform generates real-world evidence to validate efficacy and also, to size the economic impact of a given technology.

VITAL’s evidence will show if the product can apply to a broad population but also work just as well in a less-controlled environment than the trial used for FDA approval. The data generated by VITAL also can help to educate a payer or IDN on a missed opportunity. There are a number of health conditions that could be treated or diagnosed faster, or that could improve patient health or reduce costs, if payers or health systems know about an innovation and its impact.

Journal of Healthcare Contracting: What are the difficulties that healthcare providers face when trying to predict the value – in terms of outcomes and costs – of new technologies?

Tucker: Real-world evidence is playing an increasing role in healthcare decisions. The healthcare community is using these data to support coverage decisions and to develop guidelines and decision support tools for use in clinical practice.

Providers are interested in this type of evidence because it confirms which technologies are valuable. But the important thing to note is that providers aren’t trained to conduct value or economic analysis on new innovations. That isn’t their role. They want to focus on delivering great care to their patients. VITAL, however, provides a platform to accelerate the further discovery of important new technologies by identifying and validating those that providers should have in their tool kit to make patients better, faster.

Journal of Healthcare Contracting: Startup companies frequently point out that hospitals and health systems demand objective evidence of the technology’s value in terms of outcomes and cost. But the startups find it difficult to present such data, since they lack a track record. How do you help innovators deal with this problem?

Tucker: Every solution provider has to judge how much convincing they are going to need to do to gain adoption. Not all products are the same, and many inherently solve bigger problems than others, clinically or economically. For the right company, Highmark Health’s VITAL platform can be extremely beneficial because we look for technologies that are high-impact within our system as a marker of their potential nationwide. By sizing the impact they could have and validating it inside our system, VITAL can give others a relative benchmark of the impact they might see.

Journal of Healthcare Contracting: How far (how much) should our readers invest in a new company or new technology that lacks a real-world track record? Is it possible to “test the waters” before diving in?

Tucker: The problem you state is exactly why VITAL was started. We take new technologies that lack a track record, do a deep dive to determine if we have confidence they will benefit patients, and test them on a small scale to validate that they work as expected. What makes us different than a ‘pilot’ is that we are doing this in our closed system, which reduces variability and has been designed to deliver to the solution provider a data package that can be used with other payers or systems as well.

Journal of Healthcare Contracting: VITAL says it can provide innovators with “accelerated real-world tests.” Can you elaborate?

Tucker: Due to our integrated system, we are able to align the insurance side and clinical side to perform tests in a real-world environment and generate results faster. Most health systems or payers aren’t working together in the way we do, so it takes significantly longer to align everyone around a new and innovative idea that can improve care and economics, and to generate the evidence to prove the outcomes it can produce.

Journal of Healthcare Contracting: What markers does VITAL use to gauge the outcomes of a new technology? How do you decide what to measure?

Tucker: What we measure really depends on the technology we are testing. As I mentioned before, all products are very different, and we customize based on that. Generally, we are looking for clinical and economic impact: Does the product lead to better patient outcomes and does it lead to a reduction in costs for our system, our insurance plan, and ideally, our patients?

Journal of Healthcare Contracting: What are some of the components of the cost of a new technology that VITAL measures?

Tucker: We view the cost of the technology to be both the acquisition cost and any implementation costs. If a technology is difficult to implement, requires significant training, or involves a significant infrastructure for it to work, we will take that into account.

Journal of Healthcare Contracting: Clinician input and satisfaction – as well as patient satisfaction – can determine whether a technology is accepted and widely used. How do you measure this in a fairly objective way?

Tucker: To this point, we have evaluated technologies through qualitative means by asking for clinician and patient feedback. That has been sufficient to help make adoption decisions. As we expand the program, however, we want to generate quantitative measures of experience that can then be leveraged by our customers so they can more effectively explain the importance and impact of greater provider and patient satisfaction.

Journal of Healthcare Contracting: Will programs such as VITAL supersede the work currently being done by value analysis teams in health systems?

Tucker: We think they complement each other. The evidence we generate in VITAL helps make value analysis or medical policy decision-makers’ jobs easier or more effective, but each of those groups look at a number of important factors in addition to clinical or economic evidence. Not every product is a fit for VITAL. We are looking for innovations that push care forward rapidly, and there still needs to be a place to evaluate products leading to more incremental improvements.

Journal of Healthcare Contracting: Finally, in what areas of technology are you finding some of the most exciting innovations?

Tucker: We have been focusing on technologies that help us solve the biggest problems out there. Those problems represent the costliest disease states with the most patients, and they include areas such as cardiology, diabetes, orthopedic and musculoskeletal, and kidney disease. Because of the market opportunity, innovations are also very much focused here. It can get difficult to find the needles in the haystack, but the payoff when you do is worth it.

We are also interested in understanding how to treat people and their conditions on an individual level. Technologies that facilitate a clinician’s ability to treat a patient more effectively and get them healthier, faster is very important. There are some very unique and interesting diagnostics we are seeing that help determine optimal therapies or help avoid interventions that are unnecessary.