AHRQ Research Helps Business Group Develop Health Plan Coverage for GERD Treatments

Comparative Effectiveness

2007

The National Business Group on Health (Business Group) is using research from AHRQ's Effective Health Care Program to help patients and health care purchasers make informed choices. The findings in Comparative Effectiveness of Management Strategies for Chronic Gastroesophageal Reflux Disease (GERD) are being used when considering how to manage the symptoms of chronic GERD.

The Business Group seeks to improve employers' return on benefits investment and enhance the health and quality of life of employees and their dependents by linking benefit design to medical practices with demonstrated effectiveness. Veronica Goff, Senior Consultant, explains, "Results from AHRQ's GERD report were particularly meaningful to employers in their role as health care purchasers. For several years, proton pump inhibitors (PPIs) were a prime contributor to pharmacy plan spending growth."

Through its National Committee on Evidence-Based Benefit Design, the Business Group translates treatment effectiveness studies by respected sources into recommendations for coverage, purchasing, and member support. The goal is to align health benefit plans with the latest medical findings.

In March 2006, the Business Group summarized results from the GERD report, designed plan options specific to pharmacy and medical plans, and distributed its guidance through its Benefit Manager Coverage Brief. Approximately 300 copies of the Brief were disseminated to Business Group members, benefit managers, and directors (i.e., potential decision-makers and policymakers) at various conferences.

The Business Group presented various options for its membership based on findings from the AHRQ report, such as dose/quantity limits and a narrow formulary for PPIs. In addition, they recommended against covering endoscopic anti-reflux procedures until more is known about their effectiveness. Employers may use findings from the GERD report to assess their current plans and revise employee cost-sharing. Health plans could use the report to support existing coverage policies or make new recommendations regarding surgical procedures and the pharmacy benefit.

Findings from AHRQ's report and other evidence-based reviews may also affect coverage for endoscopic procedures. Health plans may be less likely to reimburse for these procedures, given that findings from the evidence review did not seem to support their use.

"For now, there is not enough evidence to justify covering endoscopic procedures for GERD," Goff says. "In terms of the pharmacy plan, consumers may see incentives to try over-the-counter PPIs before using a prescription medication."

To identify the potential impact AHRQ's report has further had on benefit plans, "We could investigate whether there were any changes in coverage for PPIs, and, if so, infer that the report contributed to the change," Goff explains.

Impact Case Study Identifier: COE-07-03
AHRQ Product(s): Effective Health Care Program
Topic(s): Gastroesophageal Reflux Disease (GERD)
Geographic Location: National

Search Impact Case Studies

Comparative Effectiveness of Management Strategies for Gastroesophogeal Reflux Disease. December 2005. AHRQ Pub. No. 06-EHC003-1. Agency for Healthcare Research and Quality, Rockville, MD. http://www.effectivehealthcare.ahrq.gov/repFiles/GERDExecSum.pdf [PDF File, 1.5 MB;].

Page last reviewed October 2014
Internet Citation: AHRQ Research Helps Business Group Develop Health Plan Coverage for GERD Treatments. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/policymakers/case-studies/coe0703.html