Many health insurers have their own assessment panels

Kaiser Health NewsJune 5, 2009 

OLYMPIA, Wash. — As many patients discover, doctors don't have the last word on treatment. Insurers generally deny coverage for anything they think hasn't been proved 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 said that while they generally agreed with the state program's decisions, their plans made their own evidence-based decisions. They said that to keep up with new technologies, they had to make more and faster decisions than the state program did.

All these technology-assessment programs rely on reviewing published scientific data on medical services, rating the strength of the evidence and comparing safety and efficacy with clinical alternatives. However, the 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 review medical evidence in-house. In other cases, they contract with outside organizations such as the Oregon Health & Science University, Hayes Inc., the Institute for Clinical and Economic Review, the ECRI Institute and Spectrum Research. Fourteen evidence-based practice centers in the U.S. and Canada funded by the federal Agency for Healthcare Research and Quality also produce technology assessment reports.

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 services, the institute considers how much a drug or treatment costs to keep a patient alive with a decent quality of life for a given period.

The U.S. isn't about to embrace the British institute as a model. President Barack Obama's $1.1 billion comparative-effectiveness research initiative was reined in even before it launched. Congress made it clear that 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 how to use the research.

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

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

Many payers, including Medicare, generally avoid explicitly considering cost while making coverage decisions about devices, tests and procedures, though they often consider it in choosing drugs for coverage.

Industry and patient groups in many cases fear that cost-based decisions undermine doctors' authority. "If you're looking purely at clinical outcomes, that's a positive step," said Thomas Novelli, the 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, the director of the Washington state program, urged the Institute of Medicine 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 2 million trials that are produced and ignored."

(Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care-policy research organization that isn't affiliated with Kaiser Permanente.)

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