Insurers Apply Different Methods In Making Coverage Decisions

As many patients discover, doctors don’t have the last word on treatment. Insurers generally deny coverage for anything they believe hasn’t been proven to work.

Washington state’s technology assessment program is unique in government circles, but public and private bill-payers routinely make coverage decisions on one basis or another. Medicare, the federal health program for the elderly, is guided by recommendations from the Medicare Evidence Development & Coverage Advisory Committee. Other prominent programs include the Blue Cross Blue Shield Association’s Technology Evaluation Center, the Blue Shield of California Foundation’s California Technology Assessment Forum, Kaiser Permanente’s New Technologies Committee, and a multi-state Medicaid collaboration with the Oregon Health & Science University. Medicaid is the state-federal program for the poor.

Experts say there’s a great deal of duplicated effort and inconsistency among payers in deciding whether to cover particular drugs, tests, devices and procedures. Even Medicare has different coverage rules for the same services across the country because it leaves many decisions to regional carriers.

In Washington state, medical directors for several private insurers say that while they generally agree with the state program’s decisions, their plans make their own evidence-based decisions. They say they have to make more and faster decisions than the state program does to keep up with new technologies.

All these technology assessment programs rely on reviewing  published scientific data on different medical services, rating the strength of the evidence and comparing safety and efficacy with clinical alternatives. But their programs vary widely in terms of transparency, comprehensiveness in reviewing evidence, openness to suggestions from doctors and others, explicit consideration of cost and opportunities for appeal.

Some payers do in-house reviews of medical evidence. In other cases, they contract with outside organizations such as Oregon Health & Science University, Hayes Inc., the Institute for Clinical and Economic Review, the ECRI Institute and Spectrum Research. Technology assessment reports also are produced by 14 evidence-based practice centers in the U.S. and Canada funded by the federal Agency for Healthcare Research and Quality.

Internationally, the best-known program is Great Britain’s National Institute for Health and Clinical Excellence, which sets coverage policy for the National Health Service. Besides assessing the efficacy and safety of different services, NICE considers how much a drug or treatment costs to keep a patient alive with a decent quality of life for a given period of time.

The U.S. isn’t about to embrace NICE as a model. President Obama’s $1.1 billion comparative-effectiveness research initiative was reined in even before it launched — Congress made clear it can’t be used to dictate coverage.

A federal coordinating council, made up of 15 government employees, mostly doctors and other medical professionals, will receive recommendations from an Institute of Medicine advisory panel by June 30 on prioritizing study areas and on how to use the research.

Some experts hope the council, working with other federal agencies, will commission original studies to address unanswered questions in high-impact medical areas, such as the best diagnostic approach when physicians suspect patients have coronary artery disease.

“If you scratch the surface, you find that the studies done don’t always answer the questions we need answered,” said Dr. Alan Garber, a Stanford University medical professor who sits on the IOM advisory panel. “With the amount of money now available, it will be possible to fund randomized trials comparing two or more services thought to be effective.”

The American College of Physicians and others also hope the council will help refine and promote the use of cost-effectiveness data in making coverage decisions.

Many payers, including Medicare, generally avoid explicit consideration of cost in their coverage decisions for devices, tests, and procedures, though they often consider it in choosing drugs for coverage.   Industry and patient groups in many cases fear cost-based decisions undermine doctors’ authority. “If you’re looking purely at clinical outcomes, that’s a positive step,” said Thomas Novelli, director of federal affairs for the Medical Device Manufacturers Association. “But when you inject costs, there will be concern.”

Given the opposition, some experts worry that the new federal research effort will fail to address the central challenge – focusing scarce resources on clinical services with proven value – because of a lack of political courage.

Leah Hole-Curry, director of the Washington state program, urged the IOM advisory panel in March to focus not just on prioritizing clinical services for study but also on recommending how best to use the research to improve patient care.

Otherwise, she warned, the new research “will just go into a pile of two million trials that are produced and ignored.”