Implementing evidence-based medicine through medicare coverage decisions

Health Affairs

Volumn 26, Issue 6, 2007, Pages 1634-1642

  Foote, Susan Bartlett ^a   Town, Robert J ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

COST CONTROL; ECONOMICS; EVIDENCE BASED MEDICINE; HEALTH CARE POLICY; HUMAN; INSURANCE; LEGAL ASPECT; MASS COMMUNICATION; MEDICARE; METHODOLOGY; POLICY; REVIEW; UNITED STATES;

COST CONTROL; DIFFUSION OF INNOVATION; EVIDENCE-BASED MEDICINE; HEALTH POLICY; HUMANS; INSURANCE COVERAGE; MEDICARE; ORGANIZATIONAL POLICY; UNITED STATES;

EID: 36849009163     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.26.6.1634     Document Type: Review

References (41)

1. R.A. Berenson, T. Bodenheimer, and H.H. Pham, "Specialty-Service Lines: Salvos in the New Medical Arms Race," Health Affairs 25 (2006): w337-w343 (published online 25 July 2006; 10.1377/hlthaff.25.w337);
2. and D.M. Cutler and M. McClellan, "Is Technological Change in Medicine Worth It?" Health Affairs 20, no. 5 (2001): 11-29.
3. See L. Baker et al., "The Relationship between Technology Availability and Health Care Spending," Health Affairs 22 (2003): w537-w551 (published online 5 November 2003; 10.1377/hlthaff.w3.537), for discussion of policy efforts to assess and manage availability of new technologies.
4. Regarding rationing, see H.J. Aaron and W.B. Schwartz, Can We Say No? The Challenge of Rationing Health Care (Washington: Brookings Institution, 2005).
5. S.B. Foote, "Assessing Medical Technology Assessment: Past, Present, and Future," Milbank Quarterly 65, no. 1 (1987): 59-80.
6. G.R. Wilensky, "Developing a Center for Comparative Effectiveness Information," Health Affairs 25 (2006): w572-w585 (published online 7 November 2006; 10.1377/hlthaff.25.w572).
7. Social Security Amendments, sec. 1801.
8. Ibid., sec. 1862[a][1].
9. The contractors were originally called fiscal intermediaries for Part A and carriers for Part B. The Medicare Modernization Act of 2003 required a consolidation of contractor regions, merged the Part A and B contractors, and gave them the new name of Medicare Administrative Contractors (MACs). These changes will be fully implemented by 2011. For clarity, we use the term "contractors" to describe this function. For updated information on implementation, see Centers for Medicare and Medicaid Services, "Medicare Contracting Reform: Overview," 15 March 2006, http://www.cms.hhs.gov/ medicarereform/contractingreform (accessed 9 August 2007).
10. For evaluation of the reform, see U.S. Government Accountability Office, Medicare Contracting Reform: CMS Plan Has Gaps and Anticipated Savings Are Uncertain, Pub. no. GAO 05-873 (Washington: GAO, August 2005).
11. S.B. Foote, "Why Medicare Cannot Promulgate a National Coverage Rule: A Case of Regula Mortis," Journal of Health Politics, Policy and Law 27, no. 5 (2002): 707-730.
12. For more discussion of NCDs, see P.J. Neumann et al., "Medicare's National Coverage Decisions, 1999-2003: Quality of Evidence and Review Times," Health Affairs 24, no. 1 (2005): 243-254.
13. For the evolution of local coverage, see S.B. Foote, "Focus on Locus: Evolution of Medicare's Local Coverage Policy," Health Affairs 22, no. 4 (2003): 137-146;
14. and S.B. Foote et al., "Resolving the Tug-of-War between Medicare's National and Local Coverage," Health Affairs 23, no. 4 (2004): 108-123.
15. The CMS posts all NCDs and LCDs on its Web site. For NCDs, see CMS, "Medicare Coverage Center," http://www.cms.gov/center/coverage.asp (accessed 9 August 2007);
16. for LCDs, see CMS, "Medicare Coverage Database," http://www.cms.hhs.gov/mcd/overview.asp (accessed 9 August 2007).
17. S.R. Tunis and S.D. Pearson, "Coverage Options for Promising Technologies: Medicare's 'Coverage with Evidence Development'," Health Affairs 25, no. 5 (2006): 1218-1230.
18. B.M. Straube, "How Changes in the Medicare Coverage Process Have Facilitated the Spread of New Technologies," Health Affairs 24 (2005): w314-w316 (published online 23 June 2005; 10.1377/hlthaff.w5.314);
19. and S.R. Tunis and J.L. Kang, "Improvements in Medicare Coverage of New Technology," Health Affairs 20, no. 5 (2001): 83-85.
20. "Renewal and Renaming of the Medicare Coverage Advisory Committee (MCAC) to the Medicare Evidence Development Coverage Advisory Committee (MedCAC) and Request for Nominations," Federal Register 72 (26 January 2007): 3853-3854.
21. Foote, "Focus on Locus"; and Foote et al., "Tug-of-War. "
22. CMS, "Local Coverage Determinations," chap. 13 in Medicare Program Integrity Manual, Sec. 13.1.3 (Rev. 186), 26 January 2007, http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf (accessed 9 August 2007).
23. J.E. Wennberg, "Practice Variations and Health Care Reform: Connecting the Dots," Health Affairs 23 (2004): VAR140-VAR144 (published online 7 October 2004; 10.1377/hlthaff.var.140);
24. and E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 273-287.
25. S. Kaul and G.A. Diamond, "Drug-Eluting Stents: An Ounce of Prevention for a Pound of Flesh?" Cardiosource: American College of Cardiology, 11 October 2006, http://www.cardiosource.com/editorials/index. asp?EdID=87 (accessed 9 August 2007).
26. See also B. Feder, "Newer Stents Pose Dangers, Two Doctors Say," New York Times, 12 October 2006.
27. Kaul and Diamond, "Drug-Eluting Stents." The CMS national coverage decision (NCD) addresses percutaneous transluminal angioplasty (PTA) with and without stenting. See the NCD for PTA (no. 20.7) posted on the CMS Medicare Coverage Database, http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=20. 7&ncd_version=3&basket+ncd%3... (accessed 9 August 2007). New codes were developed for billing for bare metal and drug-coated stents.
28. S.B. Foote et al., "The Impact of Medicare Coverage Policies on Health Care Utilization" (Unpublished paper, University of Minnesota, 2007). The cases studied included chest x-rays, toenail debridement, deep brain stimulation, Heliobacter pylori breath test, transesophageal echocardiography, abdominal and pelvic computed tomography (CT) and magnetic resonance imaging (MRI) scans, epoetin alpha for end-stage renal disease (ESRD), and ocular photodynamic therapy.
29. Ibid.
30. An example of an LCD for TEE is Highmark Medicare Services-Fiscal Intermediary, LCD M-51J - Trans-esophageal Echocardiolography (TEE), http://www.highmarkmedicareservices.com/policy/partb/m1/m51j.html (accessed 23 September 2007).
31. See remarks of Bruce Quinn in Medical Technology Leadership Forum, Mining Medicare Claims: Searching for Value in the Medicare Program, 30-31 October 2006, p. 4, http://www.mtlf.org/img/assets/24072/ Fall%20Final%20Report.pdf (accessed 9 August 2007).
32. M. Libicki and I. Brahmakulam, The Costs and Benefits of Moving to the ICD-10 Code Set, Pub. no. TR-132-DHHS (Santa Monica, Calif.: RAND, 2004).
33. M.O. Leavitt, "Report to Congress - Medicare Contracting Reform: A Blueprint for a Better Medicare," 7 February 2005, http://cms.hhs.gov/ MedicareContractingReform/Downloads/report_to_congress.pdf (accessed 9 August 2007).
34. CMS, "Functional Contractors Overview," http://www.cms.hhs.gov/ MedicareContractingReform/Downloads/FunctionalEnvironment.pdf (accessed 9 August 2007).
35. Medicare Learning Network, "The Medicare Medical Review Program," 2006, http://www.cms.gov/MLNProducts/downloads/MRFactSheetMay06. pdf (accessed 9 August 2007).
36. Wennberg, "Practice Variations"; and Fisher et al., "The Implications of Regional Variations."
37. For a discussion of the contractor infrastructure, see S.B. Foote and G.W. Halaas, "Defining a Future for Fee-for-Service Medicare," Health Affairs 25, no. 3 (2006): 864-868.
38. U.S. Department of Health and Human Services, Office of the Secretary, "HCFA, 45 CFR Parts 160-162, Health Insurance Reform: Standards for Electronic Transactions, Announcement of Designated Standard Maintenance Organizations, Final Rule and Notice," Federal Register 65, no. 160 (17 August 2000): 50312-50371.
39. Libicki and Brahmakulam, The Costs and Benefits.
40. Foote and Halaas, "Defining a Future."
41. T. Sloane, "For Comparison's Sake," Modern Healthcare (27 November 2006): 20.