Commentary: Evaluating oversight of human drugs and medical devices

This article seeks to provide insights into appropriate FDA oversight of nanotechnology. This commentary identifies limitations in the methodology employed and concludes that the analysis would be stronger with a more in-depth institutional dimension based on administrative law and political science research.

The impact of Medicare coverage policies on health care utilization

OBJECTIVE

To determine whether Medicare coverage policies affect utilization of services in Medicare.

DATA SOURCES

We constructed an analysis data set for eight different procedures using secondary data obtained from Medicare claims (1999-2002) and Medicare coverage policies posted on Center for Medicare and Medicaid Services website.

STUDY DESIGN

We analyzed the impact of coverage policies using difference-in-difference approach in a regression framework.

PRINCIPAL FINDINGS

We found that in only one case (transesophageal echocardiography) out of eight did utilization change (reduced by 13.6 percent) after the effective date of the local policies. There is no systematic pattern that policies affect utilization, and the type of coverage policy does not seem to play an important role in its impact.

CONCLUSIONS

Coverage policies have the potential but do not consistently impact utilization as policy makers intend and expect them to do. These findings raise significant policy questions about the effectiveness of Medicare coverage policies, which deserve further study.

Defining a future for fee-for-service Medicare

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) provides economic incentives that favor health plans over traditional fee-for-service (FFS) Medicare. This reflects an ideological preference for private plans rather than government-administered pricing and recognition that private plans can use tools effectively to improve quality. However, enrollment projections indicate that FFS will continue to attract the majority of beneficiaries for years to come. We argue that MMA's contractor reform provisions create the opportunity to build critical FFS infrastructure, and contractors have the potential to encourage quality and manage utilization to compete with private plans in a modernized Medicare.

Rules for medical markets: the impact of medicare contractors on coverage policies

OBJECTIVE

Examine Medicare's local contractors' claim payment rules, focusing on how technology affects the balancing of competing demands to respond to local medical markets (rule heterogeneity) with concerns about national consistency in payment rules (rule homogeneity).

DATA SOURCES

Local medical review policies (LMRPs) posted in policy sets by contractor organizations on the Centers for Medicare and Medicaid Services (CMS) website and a survey of Contractor Medical Directors.

STUDY DESIGN

We classified LMRPs based on type (NT=new technology; TE=technology extensions, and UM=utilization management), and examined the effect of technology type on LMRP focus, evidence use, policy revisions, implementation speed, and reference material citation characteristics of LMRPs using multivariate analysis.

PRINCIPAL FINDINGS

NT policies were more homogenous, as were policies among contractors related through multistate affiliation or through informal networks. UM policies were more heterogeneous. NT policies were more likely than UM policies to cite research journals as evidence while UM policies were more likely to cite medical reference materials.

CONCLUSIONS

Coverage policies associated with new technologies diffuse rapidly and are homogenous compared to utilization management coverage policies. This suggests that new technology policies are responsive to the development of new technologies at the national level. In contrast, utilization management policies are responsive to local heterogeneity in health care practice. Congress has mandated reforms to the contracting process to achieve consistency and reduce duplication. Our data elucidate the nature and sources of variation and will help policymakers strike a balance between homogeneity and local adaptation.

External review of health plan denials of mental health services: lessons from Minnesota

There has been concern that health plans unfairly deny claims for mental health services. This study examines a unique Minnesota program that resulted from a legal settlement. An independent panel reviews all mental health service denials in the state's three largest health plans. Our study analyzed every case file (N = 4717) the panel reviewed from January 2002 to August 2005. This unique dataset provides insight into health plan behavior. The findings show that the panel reversed only 2.9% of denied claims, suggesting inappropriate denials were rare. However, the panel decisions have made important improvements in contract language and patient communications.

Variation in Medicare's local coverage policies: content analysis of local medical review policies

OBJECTIVE

To assess variation in the content of Medicare's local medical review policies.

STUDY DESIGN

Six case studies to compare differences in coverage policies by diagnosis codes, procedure codes, and indications for use.

METHODS

All carrier policies from 48 carrier contracts (n = 5213) posted to the Centers for Medicare & Medicaid Services Web site were downloaded on May 31, 2001. All policies in the data set were coded based on a typology: new technology (NT), extensions of new technology (TE), and utilization management (UM) of widely used procedures. We identified policies addressing the same procedure or technology. We required at least 20 separate policies in each case study to allow meaningful comparisons. We randomly selected 1 case study of a diagnostic and 1 for a treatment modality from each policy type (NT, TE, and UM).

RESULTS

Given previous research on local carriers, we expected to find variations among policies in each case study. We found substantial similarity, however, among policies covering the NT and TE types. We found significantly more variation among our UM-type case studies.

CONCLUSIONS

Medicare legislation has called for greater coverage policy consistency in Medicare. This analysis on variation in policy content, part of a larger study on variation in Medicare's local coverage process, provides data on policy content differences. Policy reform should reflect the nature of and reasons for policy variation as suggested by the findings of this research.

Resolving The Tug-Of-War Between Medicare’s National And Local Coverage

Medicare's decentralized local coverage policy process leads to policy variation, raising serious equity and quality issues. The policy debate resembles a tug-of-war, with advocates favoring nationalization of all local policies or arguing for the status quo. We extensively analyzed thousands of local policies and surveyed Medicare's contractors. We found that all local policies are not the same. We classified them based on where they fall on the diffusion curve. The classification by type allows for reallocation to the national or local process to improve the decisions and satisfy Medicare's equity and quality goals.

Politics of prevention: expanding prevention benefits in the Medicare program

It is critical that public health advocates understand the structure of the Medicare program and the impact of the political process on Medicare's benefit set. This article provides an overview of the design of Medicare and its explicit exclusion of prevention benefits in the original legislation. We then provide a history of subsequent legislation authorizing coverage of specific prevention benefits over the last twenty years. We critique the current process in light of innovation in preventive services and the influence of politics in the decision-making. We conclude with a discussion of policy options to improve access to an appropriate range of evidence-based preventive services in Medicare within the context of new technology innovation and rising health care costs.

Focus on locus: evolution of Medicare's local coverage policy

Medicare relies on a highly decentralized local-contractor structure that emerged as a political compromise in 1965. Decisions regarding Medicare's coverage of new procedures and technologies are an important part of the program. A national coverage process exists, but Medicare's local contractors develop most coverage policies. Although an intense debate surrounds Medicare's local coverage process, there is little analysis to inform the discussion. To expand knowledge of local coverage policy, this paper traces its origins and evolution. I conclude that the focus on locus, framing the debate in terms of local versus national, obscures fundamental policy issues of access, equity, and quality in Medicare.

Why Medicare cannot promulgate a national coverage rule: a case of regula mortis

For over twenty-five years, Medicare has tried to promulgate a rule to implement the broad congressional directive to pay only for items and services that are "reasonable and necessary." A rule would clarify legal authority and describe specific criteria for evaluation of new technology in Medicare. This case study is an intractable example of a larger issue of regula mortis or dead rule. Regula mortis occurs when a mobilized interest group blocks legitimate administrative agency action, causing a regulatory stalemate. In this case, the medical device industry has prevented the implementation of a rule. The article diagnoses the condition of regula mortis, explains its effects in the Medicare case, and draws on principles of administrative law to propose remedies to break the logjam. While the case of coverage criteria is important in its own right, it has wider relevance. All health systems must grapple with the challenge of evaluating new technologies. Medicare efforts provide a starting point for the policy discussion. In our current political environment, regula mortis may be an increasingly common phenomenon and the proposed cures for it broadly applicable.

Medical technology meets managed competition

Medical technology is an integral part of health care, not an expensive add-on or afterthought. Therefore, technology policy must be consistent with the approach to health care reform. Our present market has failed to generate adequate information on new technologies and perverse economic incentives have led to overutilization. In managed competition, health plans, not government, are best suited to make most technology decisions. The federal government can provide a safety valve for specific coverage decisions and can facilitate the acquisition, evaluation, and dissemination of information on new technologies.

Beyond incrementalism. Designing an infrastructure for reform

Labeling health reform proposals comprehensive or incremental erects unnecessary barriers to constructive debate. This article explains why these labels fail to adequately describe the key issues in the debate. It offers insight into the fundamental issues of infrastructure that must be addressed in order to craft enduring reform. To accomplish infrastructure reform, a new definition of health, a return to the principles of federalism, a design for private-public partnerships, and a redesign of the federal health bureaucracy are needed. Many of these issues are relevant to mental health as well.

Certification: philosophy, goals, and methods, with application to the discipline of infection control practice

The philosophy, goals, and methods of certification are complex and need to be understood in general before they can be applied to a specific practice discipline. This article is intended to provide background information about certification, summarize the history of credentialing for health occupations, and briefly describe methods for test design and construction. Philosophy, goals, methods, and preparation for certification are then applied to the discipline of infection control practice, with specific reference to the Infection Control Certification Examination, offered for the first time in November 1983 and in each subsequent year.