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From Scientific Discovery to Covered Treatments Understanding the Payer Perspective as a Keystone to Achieving High-Value Care

22 Jun 2022 8:00 AM | Anonymous

This Viewpoint outlines some of the coverage requirements ofMedicare,3 the largest payer for health care services in the US, as an exemplar of the nuances of this key translation pipeline step. A better understanding of this process could help develop research programs, including those funded by NIH, that would generate evidence that better meets evidentiary requirements and that translate scientific discoveries into care and services that improve thehealthofindividualsandpopulations.Itmayalsostimulateinterestinunderstanding the coverage determination procedures of other large payers. Research efforts to generate evidence that meets payer requirements (ie, relevance to covered populations, improvements in health outcomes) through design and methodological clarity could accelerate the translation of scientific discoveries into clinical care and reduce health inequities. {JAMA 5.26.2022]


A better understanding of the payer perspective could facilitate achieving higher-value service delivery at multiple levels of the health care system. At the population level, improved understanding of coverage determinations could encourage the conduct of studies that support or refute the use of specific items or services in specific populations, and thus minimize risk and optimize benefits to specific populations. 

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