Our new study, recently published online in Medical Care (“Factors Predicting Medicare National Coverage: An Empirical Analysis” (1)), highlights factors underlying Medicare decisions on medical technology.
Interventions considered to be particularly controversial or expected to significantly impact the Medicare program in the United States are considered in National Coverage Determinations (NCDs). Medicare coverage for interventions is limited to eligible items and services deemed “reasonable and necessary” for the diagnosis or treatment of an illness or injury. What constitutes reasonable and necessary has not, however, been clearly defined.
This study is the first of its kind to quantitatively evaluate the factors associated with positive NCDs…
…Key findings include:
• CMS favors proven interventions. Compared to interventions with clinical evidence deemed “insufficient”, interventions with good or fair quality supporting evidence were approximately six times more likely to receive a positive decision (p<0.01).
• Interventions with available alternatives are less likely to be covered. Compared with interventions with no available alternative, those for which an alternative was available were approximately eight times less likely to receive a positive decision (p<0.01).
• CMS accounts for value in coverage decisions. Compared with technologies estimated to be dominant, i.e., more effective and less costly than the competing intervention considered, those with no published estimate of cost-effectiveness were approximately five times less likely to receive a positive coverage decision (p<0.05).
• Coverage decisions have become more restrictive over time. Compared with coverage decisions made in the years 1999 to 2001, decisions made from 2002 to 2003 were more than three times less likely to be positive (p<0.05). Decisions made from 2004 to 2005 were also more than three times less likely to be positive (p<0.1), and from 2006 to 2007 decisions were almost ten times less likely to be positive (p<0.01).
This analysis can help the medical community better understand the type of evidence that Medicare considers in NCDs. CMS and other payers may also benefit from this kind of external review of coverage decisions as it can help ensure the consistency of decisions and the integrity and accountability of the coverage process.
- Evaluating The Factors Underlying Medicare Decisions On Coverage Of Medical Technology (medicalnewstoday.com)
- Study evaluates the factors underlying Medicare decisions on coverage of medical technology (medicalxpress.com)
by WILLIAM SCHAFFNER, MD at KevinMD.com (Nov. 15, 2011)
In this cartoon, the British satirist James Gillray caricatured a scene at the Smallpox and Inoculation Hospital at St. Pancras, showing Edward Jenner administering cowpox vaccine to frightened young women, and cows emerging from different parts of people’s bodies. The cartoon was inspired by the controversy over inoculating against the dreaded disease, smallpox. The inoculation agent, cowpox vaccine, was rumored to have the ability to sprout cow-like appendages. A serene Edward Jenner stands amid the crowd. A boy next to Jenner holds a container labeled “VACCINE POCK hot from ye COW”; papers in the boy’s pocket are labeled “Benefits of the Vaccine”. The tub on the desk next to Jenner is labeled “OPENING MIXTURE”. A bottle next to the tub is labeled “VOMIT”. The painting on the wall depictsworshippers of the Golden Calf.
Have you heard the parable about the blind men and the elephant? Each is holding a different part of the animal and comes to a different conclusion about what he’s dealing with. The man holding the tail is sure it’s a rope; the one with the trunk fears a snake; the one holding the tusk is certain he has a spear. It’s all in their perspective. They’ll need to share what they each know and consider the others’ perspectives if they have any hope of understanding the true scope of what they’re facing.
And so it is when a group sits down to talk about the cost-effectiveness of vaccines. If you’re a parent who lost your child to meningitis, the cost of a vaccine dose is trivial. However, if you’re considering this from the population-based, public health decision-making perspective, the annual price tag of $387 million to administer meningococcal booster doses to all 16-year-olds is anything but trivial. If you sit on the Advisory Committee on Immunization Practices, considering, discussing and deciding how much weight to give each of these perspectives and many others is now all in a day’s work.
- Cost vs. public health (thehill.com)
- Are there any risks in having my child vaccinated? (zocdoc.com)
- More Than 690,000 Americans Have Already Been Vaccinated Against The Flu This Season, SDI Reports – Cdc Supports Expanded Access To Flu Vaccination (prweb.com)
- Childhood Immunizations and Vaccinations | Special Edition | Education.com (education.com)
- Stronger flu shots, more side effects (seattletimes.nwsource.com)
- Panel says boys should get HPV vaccine, too (sfgate.com)
- CDC Panel Recommends HPV Vaccine for Boys (onebluestocking.wordpress.com)
- Letter: Republicans and the HPV Vaccine (nytimes.com)