The Role of Real-World Evidence in Payer-Provider Collaboration
Written by: Cheryl Reifsnyder, PhD and Janna Manjelievskaia, PhD, MPH, Veradigm
In U.S. healthcare, both payers and healthcare providers face increasing pressure to improve patient outcomes while managing costs. This is partly due to the country’s current healthcare costs, which are far higher than those of other wealthy nations and still rising. U.S. out-of-pocket healthcare spending has doubled in the past 20 years, from $193.5 billion in 2000 to $388.6 billion in 2020. Even with high costs, the U.S. lags far behind other high-income nations in areas such as access to care and some health outcomes.
As a result, U.S. healthcare systems face increasing demands to deliver more care to more people at lower costs. Payers are pressured to contain costs while physicians attempt to comply with cost-containing measures without compromising the quality of patient care. However, traditional decision-making methods, often reliant on clinical trials and limited data sets, no longer provide the comprehensive insights needed to address the complexities of real-world patient care.
In this healthcare environment, real-world evidence has become a game-changer.
Real-world evidence can provide greater insight into the diverse experiences of actual patients in everyday healthcare settings. Leveraging real-world data and real-world evidence, payers and providers can collaborate more effectively. Working together, payers and providers can transform the patient experience, leading to better patient care and improved outcomes while simultaneously controlling costs.
What is real-world evidence?
The Food and Drug Administration (FDA) defines real-world data as “data relating to patient health status and/or the delivery of healthcare routinely collected from a variety of sources”. Real-world data can be collected from a broad range of sources, including:
- Electronic health records (EHRs)
- Patient files
- Medical claims databases
- Patient and disease registries
- Adverse event reporting systems
- Digital health technologies (e.g., health monitoring devices, wearables, even mobile devices and social media)
These sources vary in levels of population coverage and data quality.
Real-world data include a physician notes from the patient’s annual wellness visit, lab results, health-related social media posts, insurance claims for provided health-related services, the costs of those services, and much more. In addition to data related to patients’ health status, real-world data can also be related to health care delivery, such as diagnostic trends and treatment costs.
Patient permission is required for researchers to use real-world data. Data must also be de-identified (removal of details that might allow patients to be identified) before use.
Real-world evidence uses real-world data to investigate the effectiveness of a drug or treatment, including potential benefits and risks, in real-world clinical practice settings rather than in randomized, controlled trials (RCTs) where patient populations and study environments are closely defined and highly controlled. Using one researcher’s description:
Real-world evidence = Real-world data + analytics
Because real-world data can be collected from diverse areas of daily life beyond the scope of RCTs, the real-world evidence derived from it can generate insights beyond those from traditional clinical trials. Real-world evidence can complement existing research and help fill knowledge gaps. It can also be used to support decision-making in clinical practice, treatment coverage, and reimbursement.
Importance in healthcare
Real-world evidence is gaining traction in healthcare decision-making due to its ability to provide more comprehensive understanding of patient health outcomes than clinical trial data alone.
Although RCTs remain the gold standard for healthcare research, they cannot answer every question about drug and treatment performance in real-world settings. However, real-world evidence can complement RCT data, providing information beyond what RCTs can deliver. For instance, real-world evidence can include follow-up observations after a RCT’s conclusion. It can help researchers better understand health trends, disease burden, and product effectiveness.
While RCTs concentrate on the efficacy of a drug or treatment, real-world evidence can provide additional information on drug-related epidemiology, safety, treatment costs, and other significant information beyond the scope of traditional RCTs.
Real-world evidence can also enhance our understanding of how different treatments affect different patient populations in a broader treatment context over a more extended period. Patients in real-world settings often have characteristics and treatment experiences that differ from patients in RCTs; insights derived from real-world evidence can be invaluable for understanding a treatment’s real-world performance, especially in patient populations or sub-groups where RCTs would be unethical, infeasible, or both.
Real-world evidence can even help researchers meet post-market regulatory requirements. In 2020, 1 of every 2 FDA approvals included real-world evidence in the regulatory submissions.
Impact on payers and providers
Real-world evidence solutions can help payers make more informed decisions about treatments, coverage, and patient care strategies. Real-world evidence provides more informed safety monitoring. It enables more accurate cost/benefit analysis, giving it a critical role in payer decision-making. Real-world evidence helps decision makers determine treatment effectiveness in real-world clinical practice environments. With real-world evidence, payers improve their ability to make data-driven decisions to improve patient outcomes while controlling costs.
For providers, real-world evidence adds perspective to RCT findings. It helps providers better determine a treatment or medication’s efficacy in real-world clinical practice environments and provides disease-specific insights to guide data-driven treatment decisions.
The increasing value of real-world evidence makes payer-provider collaboration essential.
Insights derived from real-world evidence can enhance clinical effectiveness, helping providers better determine the most appropriate therapies for their patients—but only if providers can access these insights. Payers often have access to real-world data that will assist providers’ treatment decisions, but for those data to benefit patients, payers must be able to communicate it to healthcare providers at the point of care. With effective and efficient payer-provider collaboration, payers can use patient data to proactively identify care gap opportunities, then communicate these potential gaps to providers in a timely manner. Improving payer-provider communications and clinical data exchange enables them to work together to drive better patient care.
The result? Providers can deliver more informed, higher quality patient care, improving patient outcomes.
Veradigm’s real-world evidence solutions
With services at the intersection of healthcare providers, payers, and life science organizations, Veradigm is uniquely positioned to help make the promise of real-world evidence a reality in healthcare. Veradigm enables organizations to obtain real-world insights from the point of care throughout the patient journey. Veradigm’s innovative solutions enable clients to obtain timely, actionable, real-world evidence to improve patients’ experience and health outcomes. Our solutions also integrate seamlessly with other systems, facilitating the collection, analysis, and use of real-world evidence across the healthcare industry.
Veradigm’s Real-World Evidence Team
Veradigm’s Real-World Evidence Team consists of seasoned researchers, statisticians, data scientists, analysts, project managers, and programmers from diverse scientific backgrounds. These experts specialize in helping to identify, clarify, and address research questions, including but not limited to: retrospective studies, prospective data collection via patient surveys and within the physician workflow, NLP/LLMs, and custom dashboards and registries. They can analyze real-world data alongside researchers or on their behalf. Veradigm’s library of recent research publications illustrates the Real-World Evidence Team’s research expertise and the breadth and depth of our real-world healthcare solutions. The Real-World Evidence Team supports a wide range of therapeutic areas, including presentations at leading industry conferences and publications in peer-reviewed journals. Of note, the team has recently championed work in demonstrating lp(a) and apoB as important predictors of cardiovascular risk, conducted a patient-reported outcomes survey in dry eye using the Veradigm FollowMyHealth platform, used natural language processing to assess negative symptoms among patients with schizophrenia, and evaluated the effectiveness of non-statin therapies on LDL-C outcomes.
Veradigm’s Real-World Evidence Analytics Platform
The Veradigm Real-World Evidence Analytics Platform is a software-as-a-service application enabling transparent and efficient real-world data analysis. Life science and clinical research organizations utilize this platform to explore and analyze EHR data at a granular level. This powerful solution provides real-world evidence analytics in near real-time, enabling rapid analysis of diverse data sources. It follows the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) standards, making it a more efficient and reliable way to generate real-world evidence.
Capitalize on the benefits provided by real-world evidence
With the ability to complement and expand the data derived from RCTs, real-world evidence brings the promise of transformation to all areas of healthcare. While RCTs are crucial for demonstrating the efficacy of new drugs or treatments, real-world evidence delivers invaluable insights into treatment safety and efficacy in real-world patients, in real-world clinical environments—insights RCTs can’t provide. Real-world evidence also provides insights into treatment performance in various subgroups of patients not covered by most RCTs. Harnessing the insights produced from real-world evidence has become critical to providing patients with the best possible care.
Veradigm is devoted to harnessing real-world evidence and helping clients capitalize on its numerous benefits. Veradigm’s real-world evidence solutions, such as the Veradigm Real-World Evidence Analytics platform, provide the tools needed to utilize real-world evidence for enhanced decision-making, improved patient outcomes, and better control of healthcare costs. Speak to a Veradigm representative today to learn how Veradigm’s real-world evidence solutions can help transform your organization.