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Journal of General Internal Medicine

, Volume 11, Issue 5, pp 294–302 | Cite as

The review process used by U.S. health care plans to evaluate new medical technology for coverage

  • Claudia A. Steiner
  • Neil R. Powe
  • Gerard F. Anderson
  • Abhik Das
Original Articles

Abstract

OBJECTIVE: To examine the process and information used by medical directors (MDs) of private health plans to make medical coverage determinations for new medical technologies, and to assess the influence of plan characteristics on the process.

DESIGN: Cross-sectional national survey.

PARTICIPANTS: Two hundred thirty-one MDs at private health plans representing 66% and 72% of the U.S. population covered by HMOs and indemnity plans, respectively.

MEASUREMENTS: Actual and optimal review process, final decision authority, sources, and evidence used for technology coverage decisions.

RESULTS: In 96% of plans, MDs take part in the medical policy review process for new technology. However, MDs have final authority over coverage decisions in only 27% of plans. Indemnity plans are more likely to assert that MDs should be responsible for final decisions, odds ratio (OR)=3.3 (95% confidence interval [95% CI] 1.4, 10). Optimal sources of information on new technology were journals, medical society statements or practice guidelines, and opinions of national experts. Actual sources of information used differed from optimal ones; local experts were used more often than is considered optimal (p<.001). For-profit plans were more likely than nonprofit plans to use national experts, OR 2.5 (95% CI 1.3, 5.0), and practice guidelines, OR 5.0 (95% CI 2.5, 10). Randomized trials (94% of MDs) meta-analyses (61%), and reviews (42%) were considered the best evidence for making coverage decisions. Barriers to making optimal decisions were lack of timely evidence on effectiveness and cost-effectiveness, not legal or regulatory issues; HMO, small, and nonprofit plans were two to three times more likely to list lack of cost-effectiveness data than their counterparts (p<.05).

CONCLUSIONS: Although MDs are nearly always involved in the technology evaluation process, a minority of MDs retain final authority over coverage decisions. Evidence from strong scientific research designs is the most frequently cited basis for decisions, but there is need for more timely, rigorous scientific evidence on medical interventions. How a health plan evaluates a new medical technology for coverage varies with identifiable plan characteristics.

Key words

technology assessment insurance managed care evidence-based medicine medical decision making 

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References

  1. 1.
    Hall MA, Anderson GF. Health insurers’ assessment of medical necessity. Univ PA Law Rev. 1992;140:1637–1712.Google Scholar
  2. 2.
    McGivney W. Technology assessment and coverage decision making. AAPPOJ. 1994;4(5):11–7.Google Scholar
  3. 3.
    Buto K. Coverage Decisions Made by the Government. Report of the NHLBI Workshop on the Artificial Heart: Planning for Evolving Technologies. Access to Evolving Technologies: Economic Constraints. Bethesda, Md: National Heart, Lung, and Blood Institute; 1993.Google Scholar
  4. 4.
    Hummel AM, Cova JL, Gleeson S. Payer’s perspective. In: Grady ML, ed. Summary Report. New Medical Technology: Experimental or State-of-the-Art. AHCPR publication no. 92-0057. Rockville, Md: Agency for Health Care Policy and Research; June 1992;93–106.Google Scholar
  5. 5.
    Gleeson S. Blue Cross and Blue Shield Association initiatives in technology assessment. In: Gelijns AC, Dawkins HP, eds. Adopting New Medical Technology. Committee on Technological Innovation in Medicine, Institute of Medicine. Washington, DC: National Academy Press; 1994.Google Scholar
  6. 6.
    Peters WP, Rogers MC. Variation in approval by insurance companies of coverage for autologous bone marrow transplantation for breast cancer. N Engl J Med. 1994;330(7):473–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Bunker JP, Fowles J, Schaffarzick R. Evaluation of medical-technology strategies. Effects of coverage and reimbursement. N Engl J Med. 1982;306(10):620–4.PubMedCrossRefGoogle Scholar
  8. 8.
    Kalb P. Controlling health care costs by controlling technology: a private contractual approach. The Yale Law Journal. 1990;99:1109–26.PubMedCrossRefGoogle Scholar
  9. 9.
    Finkelstein ST, Isaacson KA, Frishkopf JJ. The process of evaluating medical technologies for third-party coverage. J Health Care Technol. 1984;1(2):89–101.PubMedGoogle Scholar
  10. 10.
    Greenberg B, Derzon RA. Determining health insurance coverage of technology: problems and options. Med Care. 1981;19(10):967–78.PubMedCrossRefGoogle Scholar
  11. 11.
    Towery OB, Perry S. The scientific basis for coverage decision by third-party payers. JAMA. 1981;245(1):59–61.PubMedCrossRefGoogle Scholar
  12. 12.
    Williams HM. Cancer therapy: reimbursement of new therapeutic technologies. Yale J Biology and Medicine. 1992;65:83–97.Google Scholar
  13. 13.
    Light DW. Life, death and the insurance companies (editorial). New Engl J Med. 1994;330(7):498–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Anders G. Researchers Call Insurers “Arbitrary” in Covering Bone-Marrow Transplants. The Wall Street Journal. 1994 Feb 17; Sect. B:12.Google Scholar
  15. 15.
    McGivney W, Fersch C. Aetna technology assessment. Aetna TA. 1991;1(1):1–3.Google Scholar
  16. 16.
    Boren SD. Sounding board: I had a tough day today, Hillary. New Engl J Med. 1994;330(7):500–2.PubMedCrossRefGoogle Scholar
  17. 17.
    Group Health Association of America, Inc. HMO Industry Profile, 1993 Edition. Washington, DC. 1993.Google Scholar
  18. 18.
    Health Insurance Association of America. Source Book of Health Insurance Data 1993. Washington, DC. 1993.Google Scholar
  19. 19.
    Gray J. They really should call it managed doctors. Medical Economics. 1991;64–81.Google Scholar
  20. 20.
    Sackett D, Haynes B, Tugwell P, eds. Clinical Epidemiology, A Basic Science for Clinical Medicine. Boston, Mass: Little, Brown and Company; section III. pp 245–351. 1985.Google Scholar
  21. 21.
    Mausner J, Kramer S. Epidemiology — An Introductory Text. Philadelphia, Pa: W.B. Saunders Company, 1985.Google Scholar
  22. 22.
    Issues in improving effectiveness research. In: U.S. Congress, Office of Technology Assessment. Identifying Health Technologies That Work. Searching for Evidence, OTA-H-608. Washington, DC: U.S. Government Printing Office; September 1994;77–105.Google Scholar
  23. 23.
    Powe NR, Turner JA, Maklan C, Ersek M. Alternative methods for formal literature review and meta-analysis in AHCPR patient outcomes research teams. Med Care. 1994;32(7 suppl):JS22–37.PubMedGoogle Scholar
  24. 24.
    Tools for effectiveness research. In: U.S. Congress, Office of Technology Assessment. Identifying Health Technologies That Work. Searching for Evidence, OTA-H-608. Washington, DC: U.S. Government Printing Office; September 1994;39–76.Google Scholar
  25. 25.
    Field M, Lohr K, eds. Clinical Practice Guidelines, Direction for a New Program. Institute of Medicine. Washington, DC: National Academy Press; 1990.Google Scholar
  26. 26.
    U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Program Note. Clinical Practice Guideline Development. AHCPR publication no. 93-0023; August 1993.Google Scholar
  27. 27.
    Ermann D. Hospital utilization review: past experience, future directions. J Health Polit Policy Law. 1988;13(4):683–704.PubMedGoogle Scholar
  28. 28.
    Gabel J, Fink S, Lippert C, Philhour J, Kotler F, DiCarlo S. Trends in Managed Health Care. Research Bulletin, Health Insurance Association of America; 1989;1–29.Google Scholar
  29. 29.
    Ferguson JH, Dubinsky M, Kirsch PJ. Court-ordered reimbursement for unproven medical technology: circumventing technology assessment. JAMA. 1993;269(16):2116–21.PubMedCrossRefGoogle Scholar
  30. 30.
    Anderson GF, Hall MA, Steinberg EP. Medical technology assessment and practice guidelines: their day in court. Am J Pub Health. 1993;83(11):1635–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Leaf A. Sounding board: cost effectiveness as a criterion for medicare coverage. N Engl J Med. 1989;321(13):898–900.PubMedCrossRefGoogle Scholar
  32. 32.
    Department of Health and Human Services, Health Care Financing Administration. Medicare Program; Criteria and Procedures for Making Medical Services Coverage Decisions that Relate to Health Care Technology. Fed Reg. 1989;54(18):4302–17.Google Scholar
  33. 33.
    Hillman AL. Financial incentives for physicians in HMOs. Is there a conflict of interest? N Engl J Med. 1987;317:1743–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Iglehart J. Health policy report: The American health care system, managed care. N Engl J Med. 1992;327(10):742–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Eckholm E. While Congress remains silent, health care transforms itself. New York Times. 1994 Dec 18;Sect. A:1.Google Scholar

Copyright information

© Blackwell Science, Inc. 1996

Authors and Affiliations

  • Claudia A. Steiner
    • 1
    • 5
  • Neil R. Powe
    • 1
    • 2
    • 3
  • Gerard F. Anderson
    • 1
    • 2
  • Abhik Das
    • 4
  1. 1.the Department of MedicineJohns Hopkins University School of MedicineBaltimore
  2. 2.Department of Health Policy and ManagementJohns Hopkins University School of Hygiene and Public HealthBaltimore
  3. 3.Department of EpidemiologyJohns Hopkins University School of Hygiene and Public HealthBaltimore
  4. 4.Department of BiostatisticsJohns Hopkins University School of Hygiene and Public HealthBaltimore
  5. 5.the Center for Organization and Delivery StudiesAgency for Health Care Policy and ResearchRockville

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