Resolving the tug-of-war between medicare's national and local coverage

Health Affairs

Volumn 23, Issue 4, 2004, Pages 108-123

  Foote, Susan Bartlett ^a   Wholey, Douglas ^a   Rockwood, Todd ^a   Halpern, Rachel ^a  

^a UNIVERSITY OF MINNESOTA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DATA BASE; HEALTH CARE PLANNING; HEALTH CARE POLICY; HUMAN; MEDICAID; MEDICARE; METHODOLOGY; PUBLICATION;

HEALTH CARE REFORM; HEALTH SERVICES ACCESSIBILITY; INSURANCE COVERAGE; MEDICARE; QUALITY OF HEALTH CARE; SOCIAL JUSTICE; UNITED STATES;

EID: 3242679862     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.23.4.108     Document Type: Article

References (28)

1. S.B. Foote, "Focus on Locus: Evolution of Medicare's Local Coverage Policy," Health Affairs 22, no. 4 (2003): 137-146.
2. L. Baker et al., "The Relationship between Technology Availability and Health Care Spending," Health Affairs, 5 November 2003, content.healthaffairs.org/cgi/content/abstract/hlthaff.w3.537 (16 March 2004).
3. Medicare Payment Advisory Commission, Reducing Medicare Complexity and Regulatory Burden (Washington: MedPAC, 2001).
4. U.S. General Accounting Office, Medicare: Divided Authority for Policies on Coverage of Procedures and Devices Results in Inequities, Pub. no. GAO-03-175 (Washington: GAO, 2003).
5. Ibid., Appendix VI.
6. AdvaMed, "AdvaMed Rejects GAO Findings on Medicare Local Coverage; Process Remains Key Avenue for Patient Access to New Medical Technologies," Press Release, 13 May 2003.
7. Institute of Medicine, Assessing Medical Technologies (Washington: National Academies Press, 1985).
8. At the time we downloaded the information for our study, the LMRP Web site was www.lmrp.net; the site is now www.cms.hhs.gov/mcd. Our description relates to the old Web site. The date is important because contracts may be transferred from one carrier organization to another as these organizations merge or leave the program. There were contractors either not listed on the LMRP Web site or whose policy sets were empty on our "snapshot" date. We revisited the Web site and found that most policy sets previously missing on 31 May 2001 were posted. We downloaded these "missing" policy sets on 2 April 2002. We included only those policies with original effective dates on or before 31 May 2001, and we excluded two carriers (Nebraska and Vermont) and one FI (Wyoming) that were posted after the second download.
9. Data points in our coding process included policy title; description; focus (drug, surgery, medicine); start date of comment period; start date of notice period; original effective date; Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) codes covered; evidence cited; revision dates and reasons; states covered; and dates and locations of CAC meetings.
10. Excluded categories were anesthesia; ambulance and transportation; professional service components; psychological services "incident to" provision; psychiatric partial hospitalization programs; evaluation and management; consultations; observation care; care plan oversight; discharge planning; concurrent care; emergency room; nursing home; hospice; independent laboratory and diagnostic testing facilities; x-ray supplier; collection of specimens; and payment and facility administration.
11. Medicare's automated payment systems rely on codes to identify procedures used. Contractors use the HCPCS codes. There are miscellaneous codes if no established codes exist. The HCPCS contains three sets of codes. Level I codes include CPT codes used to identify medical services and procedures furnished by physicians. Level II codes include products, supplies, and services not included in CPT codes, and Level III codes are "local" codes developed by contractors for local use (eliminated in December 2003 pursuant to the Health Insurance Portability and Accountability Act, or HIPAA).
12. S. Sudman, N.M. Bradburn, and N. Schwarz, Thinking about Answers: The Application of Cognitive Processes to Survey Methodology (San Francisco: Jossey-Bass, 1996).
13. Eight CMDs (12 percent) provided written refusals, citing time and resource constraints; two also wanted written approval from the CMS. Others refused to participate when called or did not return calls.
14. CMS, Medicare Program Integrity Manual (Manual Transmittals through Transmittal Number 52, 10 October 2003), www.cms.hhs.gov/manuals/108_pim/ pim83toc.asp (16 March 2004).
15. W.R. Scott, Organizations: Rational, Natural, and Open Systems, 5th ed. (Upper Saddle River, N.J.: Prentice Hall, 2003), 263-267.
16. Foote, "Focus on Locus."
17. The activities were LMRP development; provider relations; claims processing, payment, and recovery; administrative; fraud; beneficiary inquiries/appeals; and other.
18. A.M. Garber, "Evidence-Based Coverage Policy," Health Affairs 20, no. 5 (2001): 62-82.
19. Statement of Charlotte Yeh, former contractor for National Heritage Insurance (New England), Medical Technology Leadership Forum, 29 January 2003.
20. Contractor workgroups develop model policies that are shared with other contractors. See "Device Makers Ask HCFA to Scrap 'Clandestine' Policymaking Process," Reuters Health, 4 January 2001.
21. T.G. Thompson, Report to the Congress on National Coverage Determinations (Washington: DHHS, 2002).
22. National Heritage Insurance Company, "Local Medical Review Policy Strategy FY 2002" (Mimeo, 2002).
23. J.E. Wennberg, E.S. Fisher, and J.S. Skinner, "Geography and the Debate over Medicare Reform," Health Affairs, 13 February 2002, content.healthaffairs.org/cgi/content/abstract/hlthaff.w2.96 (16 March 2004).
24. MedPAC, Report to the Congress, Medicare Payment Policy (Washington: MedPAC, March 2004).
25. S.D. Ramsey et al., "The Limited State of Technology Assessment for Medical Devices: Facing the Issues," American Journal of Managed Care 4 (Special Issue, September 1998): SP188-SP199.
26. Garber, "Evidence-Based Coverage Policy."
27. R.A. Rettig, Health Care in Transition: Technology Assessment in the Private Sector (Washington: RAND, 1997), 11.
28. 21 U.S. Code, sec. 321. See the 1976 Medical Device Amendments to the Food, Drug, and Cosmetic Act.