Technology coverage decisions by health care plans and considerations by medical directors

Writing Effective Insurance Justification Letters for Cancer Genetic Testing: A Streamlined Approach

The topic of insurance coverage and justification letters for cancer predisposition testing has been the subject of much discussion on the National Society of Genetic Counselors Cancer Special Interest Group (NSGC Cancer-SIG) listserv. Some counselors have stated that they have had difficulty in obtaining insurance coverage for their patients, while others have indicated that they would appreciate seeing examples of successful letters. The purpose of this paper is to provide practical guidance in writing successful letters of justification and to share insurance success stories in the area of cancer genetic testing.

A systematic review of coverage decision-making on health technologies-evidence from the real world

OBJECTIVE

Quantitative analysis of real-world coverage decision-making offers insights into the revealed preferences of appraisal committees. Aim of this review was to structure empirical evidence of coverage decisions made in practice based on the components 'methods and evidence', 'criteria and standards', 'decision outcome' and 'processes'.

METHODS

Several electronic databases, key journals and decision committees' websites were searched for publications between 1993 and June 2011. Inclusion criteria were the analysis of past decisions and application of quantitative methods. Each study was categorized by the scope of decision-making and the components covered by the variables used in quantitative analysis.

RESULTS

Thirty-two studies were identified. Many focused on pharmaceuticals, the UK NICE or the Australian PBAC. The components were covered comprehensively, but heterogeneously. Seventy-two variables were identified of which the following were more prevalent: specifications of the decision outcome; the indications considered for appraisal, identification of incremental cost-effectiveness ratios, appropriateness of evaluation methods, type of economic or clinical evidence used for assessment, and the decision date.

CONCLUSIONS

Research was dominated by analysis of decision outcomes and appraisal criteria. Although common approaches were identified, the complexity of coverage decision-making - reflected by the heterogeneity of identified variables - will continue to challenge empirical research.

Health technology assessment and private payers' coverage of personalized medicine

PURPOSE

Health technology assessment (HTA) plays an increasing role in translating emerging technologies into clinical practice and policy. Private payers are important users of HTA whose decisions impact adoption and use of new technologies. We examine the current use of HTA by private payers in coverage decisions for personalized medicine, a field that is increasingly impacting oncology practice.

STUDY DESIGN

Literature review and semistructured interviews.

METHODS

We reviewed seven HTA organizations used by private payers in decision making and explored how HTA is used by major US private payers (n = 11) for coverage of personalized medicine.

RESULTS

All payers used HTA in coverage decisions, but the number of HTA organizations used by an individual payer ranged from one (n = 1) to all seven (n = 1), with the majority of payers (n = 8) using three or more. Payers relied more extensively on HTAs for reviews of personalized medicine (64%) than for other technologies. Most payers (82%) equally valued expertise of reviewers and rigor of evaluation as HTA strengths, whereas genomic-specific methodology was less important. Key reported shortcomings were limited availability of reviews (73%) and limited inclusion of nonclinical factors (91%), such as cost-effectiveness or adoption of technology in clinical practice.

CONCLUSION

Payers use a range of HTAs in their coverage decisions related to personalized medicine, but the current state of HTA to comprehensively guide those decisions is limited. HTA organizations should address current gaps to improve their relevance to payers and clinicians. Current HTA shortcomings may also inform the national HTA agenda.

Coverage policy development for personalized medicine: private payer perspectives on developing policy for the 21-gene assay

PURPOSE

Personalized medicine is changing oncology practice and challenging decision making. A key challenge is the limited clinical evidence for many personalized medicine technologies. We describe the strategies private payers employed to develop coverage policy for personalized medicine using the example of the 21-gene assay in breast cancer.

METHODS

We examined the coverage policies of six private payers for the 21-gene assay. We then interviewed senior executives (n = 7) from these payers to elucidate factors informing coverage decisions. We additionally focused on the timing of payer decisions compared with the timing of evidence development, measured by publication of primary studies and relevant clinical guidelines.

RESULTS

The 21-gene assay became commercially available in 2004. The interviewed payers granted coverage between 2005 and 2008. Their policies varied in structure (eg, whether prior authorization was required). All payers reported clinical evidence as the most important factor in decision making, but all used some health care system factors (eg, physician adoption or medical society endorsement) to inform decision making as well. Payers had different perceptions about the strength of clinical evidence at the time of the coverage decision.

CONCLUSION

Coverage of the 21-gene assay is currently widespread, but policies differ in timing and structure. A key approach private payers use to develop coverage policies for novel technologies is considering both clinical evidence and health care system factors. Policy variation may emerge from the range of factors used and perception of the evidence. Future research should examine the role of health care system factors in policy development and related policy variations.

From Medical Invention to Clinical Practice: The Reimbursement Challenge Facing New Device Procedures and Technology—Part 2: Coverage

This paper, the second of 3 that discuss the reimbursement challenges facing new medical device technology in various issues of this journal, explains the key aspects of coverage that affect the adoption of medical devices. The process Medicare uses to make coverage determinations has become more timely and open over the past several years, but it still lacks the predictability that product innovators prefer. The continued uncertainty surrounding evidence requirements undermines the predictability needed for optimal product planning and innovation. Recent steps taken by the Centers for Medicare and Medicaid Services to provide coverage in return for evidence development should provide patients with access to promising new technologies and procedures while generating important evidence concerning their effectiveness.

Decisions to adopt new technologies at the hospital level: Insights from Israeli medical centers

Objectives: New medical technologies have been identified as the leading cause of increasing health-care expenditures. Adoption of a new technology is one of the most important decisions in medical centers. The objectives of this study were to map and describe the function of hospital decision-makers within the area of new technology assessment and adoption, and to examine relevant considerations, sources of information, and decision-making processes in the adoption of a new technology.

Methods: A questionnaire was mailed to hospital executives and referred to (i) the considerations for and against adoption of a new technology, (ii) the decision-making process, (iii) information sources used in the decision-making process.

Results: The most frequent criteria favoring adoption included increased cost-effectiveness, increased efficacy, and decrease in complication rates. An increase in complication rates or side effects and decreased efficacy were the top ranked criteria against adoption. The final decision-making responsibility varied among technologies; the medical director frequently made the final decision when a new device was involved, but this responsibility decreased when a new drug or a new procedure was considered. Participation in scientific meetings, opinions of local experts, medical journals, and Food and Drug Administration clearance documents were the most important information sources used in the decision-making process. However, these were not necessarily the optimal sources of information. Significant barriers in adoption decision-making are lack of timely data regarding the safety of the new technology, its cost-effectiveness, and efficacy.

Conclusion: To improve the adoption decisions, hospitals must develop criteria upon which the decision-making will be based.

Improving fairness in coverage decisions: performance expectations for quality improvement

Patients and physicians often perceive the current health care system to be unfair, in part because of the ways in which coverage decisions appear to be made. To address this problem the Ethical Force Program, a collaborative effort to create quality improvement tools for ethics in health care, has developed five content areas specifying ethical criteria for fair health care benefits design and administration. Each content area includes concrete recommendations and measurable expectations for performance improvement, which can be used by those organizations involved in the design and administration of health benefits packages, such as purchasers, health plans, benefits consultants, and practitioner groups.

Geographic variation in posttreatment surveillance intensity for patients with cutaneous melanoma

BACKGROUND

We investigated whether geographic determinants could account for variation in posttreatment melanoma surveillance intensity among plastic surgeons.

METHODS

A custom-designed questionnaire was mailed to U.S. and non-U.S. members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked how they use 14 specific follow-up modalities during years 1 to 5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year postsurgery, U.S. census region, metropolitan statistical area (MSA), and managed care organization (MCO) penetration rate.

RESULTS

Of the 1,142 respondents, 395 were evaluable. Those who did not perform melanoma surgery or follow-up were excluded. Correlation analysis showed that mean follow-up intensity for the modalities surveyed was highly correlated across TNM stages and years postsurgery. Within MSAs, only chest radiograph utilization varied significantly. The pattern of testing varied significantly by geographic region for seven modalities (office visit, computed tomography scan of the brain and chest/abdomen, alpha-fetoprotein level, 5S-cysteinyl dopa level, abdominal ultrasonogram, bone scan); in each of these, utilization by non-U.S. surgeons exceeded utilization in any U.S. census region. The pattern of testing varied significantly by MCO penetration rate for chest radiograph (greater utilization in the lowest MCO penetration rate areas) and 5S-cysteinyl dopa level (greater utilization in the highest MCO penetration rate areas).

CONCLUSIONS

The intensity of posttreatment surveillance recommended by ASPRS members caring for patients with cutaneous melanoma varies markedly. This analysis provides the first evidence that geographic factors significantly affect the surveillance strategies of clinicians following patients with cutaneous melanoma. Variation by census region was most prominent, although the size of detected differences was small.

Conventional radiography, rapid MR imaging, and conventional MR imaging for low back pain: activity-based costs and reimbursement

PURPOSE

To incorporate personnel and equipment use time in an activity-based cost comparison of conventional radiography and conventional and rapid magnetic resonance (MR) imaging for low back pain (LBP).

MATERIALS AND METHODS

At each of four Seattle Lumbar Imaging Project (SLIP) sites, patients were randomized to undergo conventional radiography or rapid MR imaging of the lumbar spine. For sample SLIP patients and for similar non-SLIP patients undergoing conventional lumbar spine MR imaging as usual care in calendar year 2000, measured imaging room use and technologist and radiologist times were multiplied by costs per minute of standard equipment acquisition, personnel compensation, and related expenses. Resulting provider-perspective costs and Seattle area Medicare reimbursements for conventional MR imaging and radiography for calendar year 2001 were used to estimate future "normative" reimbursement for rapid MR imaging.

RESULTS

For 23 conventional radiography, 27 rapid MR imaging, and 38 conventional MR imaging examinations timed in calendar year 2000, all rapid MR imaging times exceeded those of conventional radiography but were less than those of conventional MR imaging. All 0.3- and 0.35-T MR imaging room and technologist times exceeded those for 1.5-T MR imaging. Average costs (in 2001 dollars) were $44 for conventional radiography, 126 US dollars for 1.5-T rapid MR imaging, 128 US dollars for 0.3-0.35-T rapid MR imaging, 267 US dollars for 1.5-T conventional MR imaging, and 264 US dollars for 0.3-0.35-T conventional MR imaging. Conclusions regarding cost differences between conventional radiography and rapid MR imaging were robust to plausible parameter value changes evaluated in sensitivity analyses. Conventional radiography reimbursement was 44 US dollars. Applying the ratio of reimbursement (620 US dollars) to costs (264-267 US dollars) for conventional MR imaging to rapid MR imaging costs predicted reimbursement of 292-300 US dollars for the new modality.

CONCLUSION

Times and costs for rapid MR imaging are roughly three times those for conventional radiography but about half those for conventional MR imaging for LBP. While current conventional radiography costs exceed reimbursement, current conventional MR and projected rapid MR imaging reimbursements exceed costs.

Comparative economic analyses of minimally invasive direct coronary artery bypass surgery

OBJECTIVE

This study was undertaken to assess the degree to which published cost comparisons of minimally invasive direct coronary artery bypass through a thoracotomy versus conventional coronary artery bypass grafting, off-pump bypass surgery through a sternotomy, or angioplasty with or without stenting adhered to existing guidelines for performing economic analyses.

METHODS

We used minimally invasive direct coronary artery bypass (MIDCAB), off-pump bypass surgery, cost-effectiveness, economic analysis, and related keywords to search MEDLINE, other literature databases and article reference lists for English-language economic analyses of minimally invasive direct coronary artery bypass procedures versus other procedures that were published from 1990 to February 2002. We critically appraised article adherence to a 10-item methodologic checklist modified to address issues particularly relevant to minimally invasive direct coronary artery bypass evaluations. Assessment discordance was reconciled by consensus.

RESULTS

Ten articles published from June 1997 to March 2001 compared costs and (generally) outcomes of minimally invasive direct coronary artery bypass with those of other procedures. All were nonrandomized comparisons, generally of concurrent intrainstitutional clinical series. Stated results generally favored minimally invasive direct coronary artery bypass, angioplasty, or off-pump bypass surgery through a sternotomy relative to conventional coronary artery bypass grafting. Studies adequately addressed an average of only 24% of applicable checklist items (range 0%-67%). Few studies adequately ensured the comparability of treatment groups, clearly performed intent-to-treat analyses, comprehensively and credibly measured costs that were considered, or clearly addressed costs and results of preprocedural angiography or postprocedural imaging. Only 1 study compared success of revascularization between minimally invasive direct coronary artery bypass and competing alternatives. No studies specified the cost-analysis perspective or included costs of physician or physician assistant care.

CONCLUSIONS

Most published comparative economic analyses of minimally invasive direct coronary artery bypass have failed to adequately address issues crucial to such evaluations. Future studies should more closely follow well-described principles of clinical epidemiology and cost-effectiveness analysis.

The principles of cost-effectiveness analysis and their application

The current healthcare environment requires the evaluation of both the costs and benefits of alternative interventions for a given clinical problem. Given the increased interest in the economic evaluation of healthcare interventions, this article briefly defines various forms of economic evaluations and describes some useful steps for conducting appraisals of cost-effectiveness analyses. Studies of competing methods of treatment of abdominal aortic aneurysms greater than 5 cm are used as a clinical example of interest to the readers of this Journal. Rather than actually conducting such an analysis with existing data, we describe the principles for conducting or reviewing an economic analysis with factitious data.

Twenty years of health care economic analysis in Spain: are we doing well?

The rising demand for health care, together with the scarce available resources, has increased the use of economic analysis as a support tool for policy making. The objective of this study was to make a description of economic evaluation studies carried out in Spain and published during the last 20 years, and to assess their quality. A systematic bibliographic search was made in the main biomedical databases. Full economic evaluation studies made in Spain comparing two or more health care alternatives were included. Statistical analyses included a descriptive analysis, the assessment of the association between pairs of variables, and a homogeneity analysis. A total of 87 studies were included in the review. According to the methodology, the technique most frequently used was cost-effectiveness analysis. In most cases, some weaknesses could be pointed out: absence of any objective directly linked to the decision-making process, a non-explicit perspective, no inclusion of indirect costs, or clinical and economical data not concurrently collected. A continuing challenge for health care economic analysis in Spain is to follow methodological guidelines and reporting conventions, to improve the dissemination of research, as well as to use more sophisticated economic analysis techniques, and to publish in international journals.

Insurance reimbursement for risk-reducing mastectomy and oophorectomy in women with BRCA1 or BRCA2 mutations

PURPOSE

Risk-reducing surgery is an important option for women with BRCA1 and BRCA2 mutations. There are reports in the literature that insurance reimbursement for these procedures varies greatly. Because health insurance coverage significantly affects medical decision-making, current information regarding reimbursement practices of third-party payers is needed.

METHODS

Retrospective study of hospital billing records of 38 women with documented BRCA1 or BRCA2 mutations who underwent either a risk-reducing mastectomy or a risk-reducing oophorectomy between March 1, 1997, and July 30, 2000.

RESULTS

Complete billing and reimbursement information was available for 35 women undergoing a total of 39 risk-reducing surgeries. A total of 38 of 39 (97%) risk-reducing surgeries were covered in full, less applicable coinsurance and deductibles. The rate of insurance reimbursement did not vary with type of insurance, personal history of cancer, or type of procedure.

CONCLUSION

Insurance carriers reimbursed the vast majority of BRCA mutation carriers undergoing risk-reducing surgery.

Managed care, medical technology, and health care cost growth: a review of the evidence

Although managed care plans reduce health care expenditures at any point in time, less is known about whether such plans control health care cost growth. Because use of new medical technology is an important determinant of cost growth, the impact of managed care on utilization of medical technology will largely determine whether managed care can reduce expenditure growth to sustainable levels. This article reviews the literature relating medical technology to cost growth and the literature examining the impact of managed care on either cost growth or on the diffusion of medical technology. Studies that examine plan-level data often reach different conclusions than studies that examine market-level data. The evidence suggests that managed care, as currently practiced, may reduce the rate of cost growth. However, managed care is unlikely to prevent the share of gross domestic product spent on health care from rising unless the cost-increasing nature of new technology changes.

Managed care and assessment of clinical outcomes

While managed care strategies have been associated with reductions in the utilization of clinical resources, their impact on health care outcomes in general, and women's health services, in particular, remains unclear. This review summarizes recent literature regarding the impact of managed care on clinical resource use, outcomes of women's health services, and cost effectiveness of women's health care processes. Implications of these findings for women's health providers, women's health services and policy, and health services research are discussed.

Are we ready to use cost-effectiveness analysis in health care decision-making? A health services research challenge for clinicians, patients, health care systems, and public policy

The dominance of managed care as an organizing principle for health care delivery suggests that cost-effectiveness analysis (CEA) may be applied increasingly to decision-making at all levels. Health services researchers now need to address questions of how to further the underlying methods of CEA, how to make it a more practical tool for market-based as well as public policy decisions, and how to enhance CEA's ability to lead to responsible decisions that result in more effective and efficient care.

Health care CBA and CEA from 1991 to 1996: an updated bibliography

OBJECTIVES

This article updates, through 1996, a previously published bibliography of health-care cost-benefit and cost-effectiveness analysis, which described the literature from 1979 to 1990.

METHODS

A systematic search of MEDLARS databases was conducted for all articles falling under the medical subject headings "cost-benefit analysis" (which includes cost-effectiveness analysis) and "costs and cost analysis," as well as any article with the term "cost" in the title or abstract. All titles and abstracts were scanned to determine whether articles pertained to personal health services and whether both costs and consequences were assessed. If both criteria were met, the article was included in the bibliography.

RESULTS

This search resulted in 3,539 eligible cost-benefit/cost-effectiveness analysis publications from 1991 through 1996. Publications were subdivided into two major categories: reports of studies and "other" publications, including reviews, descriptions of methodology, letters, and editorials. Reports of studies and "other" publications were classified into approximately 250 different topic areas. Studies were further classified by parameters such as study type, publication vehicle, and medical function. This article describes the results of this classification and describes trends during 1991 to 1996 as compared with 1979 to 1990. OVERVIEW OF CONTENTS: The entire bibliography is reproduced in Appendix A. The classification of study reports and "other" publications into topic areas is presented in Appendix B, with numbered references to all bibliography entries. Detailed tables of findings are presented in Appendix C, and the results are illustrated graphically in Appendix D.