Government plan administrators know that navigating treatment options can be a complex and daunting undertaking for patients and clinicians alike. Amid a sea of information, how best to decide which path to take and which to avoid? For many administrators, clinicians, and patients, the decision comes down to evidence-based guidelines.
What Are Evidence-Based Guidelines?
Evidence-based guidelines are clinical criteria based on scientific studies, peer-reviewed literature, and accepted practice patterns of the American Academy of Ophthalmology and the American Optometric Association (or the appropriate bodies for the field of medicine in question).
Critical to the value of evidence-based guidelines is the quality of medical evidence supporting specific recommendations, with a structured methodology to support it. Randomized, multicenter, controlled, double-masked studies, and/or high-quality systematic reviews with meta-analysis provide the best evidence regarding the efficacy of any intervention.
Cohort studies, case-controlled studies, case series, case reports, small sample uncontrolled non-randomized prospective studies, and retrospective case reviews provide lower levels of confidence in the efficacy of an intervention.
The quality of medical evidence will inform an evaluation of how treatments, surgeries, technologies, and other interventions affect patient health outcomes, the magnitude of that effect, and its applicability to clinical practice.
Why Follow Evidence-Based Guidelines?
Healthcare is expensive. How can you be certain that your dollars are spent prudently and will give value to patients and beneficiaries? Plan administrators, clinicians, and patients (including their families) all benefit from the use of evidence-based guidelines because they ensure that care is delivered with quality and in a safe and ethical manner for all members while considering the unique situations and circumstances of the member in need of care.
Evidence-based guidelines ensure consistency in medical necessity decision-making so that health plans and their members can be assured that decisions are being made in their best interest based on science, not opinion.
Among the pitfalls of not using evidence-based guidelines, health plans, patients, and beneficiaries would pay for treatments, procedures, therapies, or medications that would not bring value to their vision, overall healthcare, or quality of life. In fact, without the use of evidence-based guidelines, the process of medical review could be influenced by non-clinical factors, such as cost or the opinion or past experience of the medical review director.
Versant Health Is Committed to Evidence-Based Guidelines
Versant Health offers vision care in accordance with evidence-based guidelines to ensure that each member receives the highest quality of care possible.
At Versant Health, our Medical Policy Council reviews peer-reviewed literature to assess the evidence-based medicine supporting a particular procedure, therapy, treatment, or medication. We then create the medical necessity criteria based upon that judgment consistent with the Preferred Practice PatternÒ Guidelines of the American Academy of Ophthalmology and the Clinical Practice Guidelines of The American Optometric Association. In this manner, you can be assured that healthcare dollars are spent for the benefit of clients, patients, and beneficiaries.
Plan administrators and members can be confident that at Versant Health reviewers are making decisions based on scientific evidence and appropriate evidence-based guidelines. For Medicare beneficiaries, Versant Health utilizes CMS National and Local Coverage Determination guidelines where available. When there are no CMS guidelines available, Versant Health uses proprietary medical policies, which are peer-reviewed, evidence-based guidelines referenced by literature and scientific studies, and practice pattern guidelines.
The use of evidence-based guidelines is just one of the many ways Versant Health ensures that member well-being and high-quality care for all are our top priorities. We hope that you will contact us below for more information.