Update. Highmark BCBS also has an innovation program, called VITAL Innovation; see a Genomeweb article here and the program's website here. The program is "Highmark-funded." Biocept has had a liquid biopsy test under VITAL, here.
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For some years, CMS has developed a long list of variably successful programs for "coverage with evidence development." In November, CMS proposed one of the largest and most complex CED programs, for molecular oncology, which is expected to be finalized by February 28.
Meanwhile, it is a cliche' that commercial payers don't do much in the CED space.[*] However, CareFirst has a formal program called HealthWorx that is gathering increased attention. I've pulled together a few links.
CareFirst is a BCBS plan serving 3.2M members in Maryland, D.C., and northern Virginia. The current CEO is Chet Burrell, who has served since 2007. He was previously an EVP for Anthem and before that held several state government positions in New York.
A January 2018 article in Baltimore Business Journal describes the HealthWorx program as "working with biotech companies to validate innovative, cheaper health care options" and bring them to its members. The insurer "searches across the country for innovations and new technologies that fit the criteria" and then the company and CareFirst collaborate in programs that test the innovation in CareFirst members. After time, a plan-wide coverage decision can be made. According to this article, it's working actively with 5 companies, talking to a dozen, and could grow in scale to work with 25 companies at a time.
A pilot program with Exosome Diagnostics was announced in August 2017, for tests that would make prostate cancer care pathways more efficient and accurate (also here and here and here). A pilot program with Myriad Genetics was announced in November 2017, looking at pilot coverage for the Vectra DA test in rheumatoid arthritis.
Key point: The Exosome Diagnostics pilot program led rapidly to full coverage for appropriate patients of the ExoDx Prostate IntelliScore (EPI) test in January 2018. The $500 molecular test could displace more costly $2000 biopsies. The CEO told the Baltimore Business News, ""This is something we could offer to our members that is less expensive, less invasive and more accurate than current options...It illustrates exactly the kind of thing we are looking to do with HealthWorx."
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Cross-reference: Illumina announced a collaborative coverage plan with Partners Health Plan in January 2018.
Tidbit: Not directly related to CareFirst, but there is a Boston-based consultance ALVA10 which aims to help diagnostic innovators collaborate early and rapidly with payers.
Tidbit: The HealthWorx trademark dates to 4/2017.
Tidbit: A San Mateo, California, regional Medicaid plan also uses the term "HealthWorx."
Tidbit: The Chief Medical Officer at Carefirst was Dr. Rahul Rajkumar (as of 2016), here, but he moved to BCBS in early 2018, according to a press release.
Tidbit: Also focused on cost saving innovation, the West Health Cost Innovation Summit was held in DC on 2/21/2018, here.
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CareFirst is looking for innovation that reduces costs ("really.") This is sometimes termed, "reverse innovation" which seems like a terrible term to me. See an article by Govindarajan in Lancet 2017 here and a forthcoming Amazon book by him, published by Harvard Business School, here (6/2018).
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[*] While I've quoted the cliche' there is not much commercial CED, there is a fairly lively dialog on at risk contracts in biopharma. See a 2017 "Forum" (open access) at J Managed Care & Specialty Pharmacy here, and 2017 blog at Deloitte here, and an article on Value Based Contracts at National Pharmaceutical Council here and a June 2017 article in Managed Care Executive here. A 2017 survey by the Academy of Managed Care Pharmacy is here and a 2017 survey of both US and European stakeholders is here.
