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Healthcare Plans as Gatekeepers

Alternative Medicine
  • Grace Powers Monaco
  • Gilbert Smith
Part of the Biomedical Ethics Reviews book series (BER)

Abstract

Healthcare plans have traditionally covered standard medical care. This category includes therapies generally recognized as beneficial to patients by medical consensus, or, increasingly, in the last thirty years, particularly as pertains to therapies for life-threatening illness, includes therapies demonstrated effective through the results of scientifically adequate clinical trials. The experimental/ investigational exclusion clause became part of most health care plan contracts by the mid-1970s. This exclusion clause recognized a division ofresponsibility. Healthcare plans covered standard therapies—those that had already been sorted out through medical consensus or clinical trial. The federal government, pharmaceuticals, and philanthropy covered the costs relating to the development of new and improved therapies as part of a social/ public obligation or commercial interest. In the last 30 years, acceptance of new therapies into a benefit package has been increasingly contingent upon demonstration of their therapeutic worth through clinical trials producing usable outcome data. Therapies antedating that period are included based on medical consensus, which is usually reflected in drug or procedure compendia.

Gatekeeping by healthcare plans became publicly visible during the mid-1970s and involved the application of the experimental/investigational exclusion to unproven and untested therapies—usually quackery or “fringe” medicine. The courts generally upheld the exclusion from coverage of therapies that had no systemic process in place to study a therapy and produce reliable outcome information on whether it could be expected to benefit patients. Application of the exclusion in this fashion was considered to be appropriate for the wise use of premium dollars. With the erosion offederal support for treatment development through support of patient care costs for participating in clinical trials, the gatekeeper function has expanded beyond “fringe” medicine to the appropriate coverage of specific applications of high-technology medicine, such as high-dose chemotherapy with autologous, allogeneic, or cord-blood rescue while still in clinical trial.

Examination of cases involving “fringe” medicine vis a vis standard therapies or those on clinical trial appears to demonstrate that the gatekeeper function has been applied evenhandedly to therapies regardless of their provenance. The underlying requirement for coverage is the level of objective, reliable, and verifiable data that is available on the approach and whether it has demonstrated that it can be expected to benefit the patient or that the patient will be participating in a scientifically adequate study that will produce information on the place of the therapy in the medical armamentarium. It would be unfair to have a double standard of gatekeeping for so-called “alternative” therapies. To win coverage as a basic benefit, “alternative ” therapies should be expected to participate in systems, appropriate to their particular class of therapy, that will produce objective and verifiable data on patient benefit.

Keywords

Alternative Therapy Health Care Plan Healthcare Plan United States Pharmacopeial Convention Blue Cross Blue Shield 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Copyright information

© Springer Science+Business Media New York 1998

Authors and Affiliations

  • Grace Powers Monaco
  • Gilbert Smith

There are no affiliations available

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