Comparative Effectiveness

How is Washington State using evidence-based medicine?

A paper by Rothman et al. (2017) explains what goes on at the Washington Health Technology Assessment Program’s (WHTAP), the first state-administered health technology assessment (HTA) program in the U.S.:

Over the past 9 years, Washington State has been pursuing an innovative and generally effective program to use evidence-based medicine to determine state health care coverage decisions. Its Health Technology Assessment Program committee evaluates diagnostic and therapeutic technologies—except pharmaceuticals, the responsibility of a different group—by the criteria of safety, efficacy, and cost-effectiveness.

How are new diagnostic and therapeutics to be evaluated?  The answer is purely based on cost. As one state official said:

We will be looking for emerging or fast-growing technologies that could have the biggest impact on the state’s budget.

Once treatments are selected, WHTAP determines whether to cover a technology, cover it with conditions, or simply deny coverage.  These decisions affect coverage decisions for state employees, Medicaid, state worker’s compensation programs and correctional health.  Between 2007 and 2013, 67% of technologies of the 39 technologies that were reviewed were covered with conditions, 26% denied, but only 8% covered with no conditions. The key factors affecting this decision were lack of efficacy and lack of safety; a lack of cost-effectiveness only because relevant for technologies with significant capital outlays (e.g., robotic surgery purchases). The factor with the smallest influence was cost-effectiveness.

While using treatments supported by evidence is clearly a good thing, the effect of WHTAP’s decisions on state finances or clinical outcomes is not well known as data are limited.  Further, practicing top-down medicine to identify treatments that are high-value for the average patient may be problematic if there exists significant clinical heterogeneity that physicians, nurses or other health professionals can observe on the ground, but that WHTAP committee members may not be able to see.  Identifying evidence-based treatments is useful; however, we need to keep medical decision-making in the hand of the physician-patient relationship informed by–rather than mandated by–evidence based medicine.



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