Adopting New Medical Technology (1994) / Chapter Skim
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6. DECISIONMAKING IN THE HEALTH CARE FINANCING ADMINISTRATION
6. DECISIONMAKING IN THE HEALTH CARE FINANCING ADMINISTRATION
Pages 87-95
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From page 87... ...
Congress intended that it protect elderly individuals from the catastrophic costs of expensive hospitalizations and post-acute care. The benefits package reflects that purpose: Medicare provides coverage for a broad range of benefits related to hospital care, physicians' services, home health care, skilled nursing care, medical equipment, and laboratory services.
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From page 88... ...
Only about 10 to 20 national coverage decisions regarding new treatments and procedures are made each year, ranging from significant medical breakthroughs, such as liver transplants, to more modest changes in diagnostic technology, such as new uses of ultrasonography. Generally, an item is referred for a national coverage decision if it has the potential for rapid diffusion, is significantly expensive, or there is a wide variation in coverage among contractors.
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From page 89... ...
Concerns exist about the length of time that it takes for national Medicare coverage decisions to be made, possible duplication with Food and Drug Administration review of devices or drugs, and general discomfort that decisions are made "in the dark" (National Advisory Council on Health Care Technology Assessment, 1988~. The proposal to include cost-effectiveness as a criterion for Medicare coverage raised concerns on the part of providers, physicians, manufacturers, and beneficiaries that Medicare would use this yardstick as a way to unduly restrict coverage of new items and services (McCarthy et al., 1989~.
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From page 90... ...
In considering any changes in the current coverage process, the Medicare program must find ways to balance the need for public input in decisionmaking with better flexibility to modify or change coverage decisions over time. PAYMENT CHANGES Although dissatisfaction with the current coverage process has highlighted the need to modify the current Medicare coverage system, the driving force for greater uniformity and clarity in Medicare coverage of technologies and procedures is from changes in Medicare payment methodologies.
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From page 91... ...
. For echocardiography, a combination of non-specific coverage guidelines, the available payment under the Medicare program, and inexpensive equipment has contributed to a rapid growth in spending, from $40.8 million in 1988 to $405.3 million in 1991 (data from the Medicare Decision Support System, BDMS, HCFA, 1991 National Claims History Data System)
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From page 92... ...
This process is akin to the one used by Blue Cross and Blue Shield's Technology Evaluation and Coverage Program, which makes recommendations on coverage for selected technologies for local Blue Cross and Blue Shield plans (see chapter 7~. HCFA is also considering contracting out some aspects of technology assessments, including literature reviews or analyses of the quality of medical evidence supporting the use of a medical practice or technology.
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From page 93... ...
Over time, HCFA expects practice guidelines, whether developed through AHCPR or other organizations using similarly rigorous methods, to play an increasingly important role in defining coverage parameters and medical review criteria and in raising questions about the appropriateness of existing coverage. HCFA is also moving ahead on its own to use Medicare patient data and medical society practice guidelines to assess patterns of e are for hospitals.
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From page 94... ...
For example, Medicare could limit coverage of certain diagnostic tests routinely administered if it appears that they add little or no value to improved diagnosis or treatment of coronary artery disease. Coverage policy, designed to ensure access for beneficiaries to appropriate medical technologies and services, falls short to the extent that current payment rules dictate the site of service for a given technology or create incentives to use an expensive technology when a more cost-effective alternative exists.
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From page 95... ...
1989. Criteria and procedures for making medical services coverage decisions that relate to health care technology.
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