Medicare is scrutinizing evidence more tightly for national coverage determinations

Health Affairs

Volumn 34, Issue 2, 2015, Pages 253-260

  Chambers, James D ^a   Chenoweth, Matthew ^a   Cangelosi, Michael J ^a,b   Pyo, Junhee ^a,c   Cohen, Joshua T ^a   Neumann, Peter J ^a,d  

^a TUFTS MEDICAL CENTER   (United States)

^b Boston Scientific ^*  (United States)

^c WORLD HEALTH ORGANIZATION   (Switzerland)

^d TUFTS UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DIAGNOSTIC IMAGING; HEALTH CARE ACCESS; HEALTH CARE POLICY; HUMAN; MEDICAL DEVICE; MEDICAL PROCEDURES; MEDICAL SERVICE; MEDICAL TECHNOLOGY; MEDICARE; PATIENT COUNSELING; PHARMACEUTICAL CARE; PRACTICE GUIDELINE; STANDARD; UNITED STATES; BIOMEDICAL TECHNOLOGY ASSESSMENT; COST BENEFIT ANALYSIS; ECONOMICS; EVIDENCE BASED MEDICINE; GOVERNMENT; HEALTH CARE DELIVERY; INSURANCE; MULTIVARIATE ANALYSIS; ORGANIZATION; STANDARDS; STATISTICAL MODEL;

CENTERS FOR MEDICARE AND MEDICAID SERVICES (U.S.); COST-BENEFIT ANALYSIS; DECISION MAKING, ORGANIZATIONAL; EVIDENCE-BASED MEDICINE; HEALTH SERVICES ACCESSIBILITY; HUMANS; INSURANCE COVERAGE; LOGISTIC MODELS; MEDICARE; MULTIVARIATE ANALYSIS; PRACTICE GUIDELINES AS TOPIC; TECHNOLOGY ASSESSMENT, BIOMEDICAL; UNITED STATES;

EID: 84922707532     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.2014.1123     Document Type: Article

References (22)

1. Twachtman G. Role of cost and evidence in value-based purchasing highlighted by Zaltrap price adjustment. Pink Sheet [serial on the Internet]. 2012 Dec 24 [cited 2014 Dec 17]. Available from: http://www.pharmamedtechbi.com/publications/the-pink-sheet/74/52/role-of-cost-and-evidence-in-valuebased-purchasing-highlighted-byzaltrap-price-adjustment
2. Silverman E.Which drugs are CVS Caremark and Express Scripts restricting? Wall Street Journal Pharmalot [serial on the Internet]. 2014 Aug 6 [cited 2014 Dec 17]. Available from: http://blogs.wsj.com/pharmalot/2014/08/06/whichdrugs-are-cvs-caremark-and-expressscripts-restricting-look-here/
3. Sullivan SD, Watkins J, Sweet B, Ramsey SD. Health technology assessment in health-care decisions in the United States. Value Health. 2009;12(Suppl 2):S39-44.
4. Washington State Health Care Authority. Health Technology Assessment program [Internet]. Olympia (WA): HCA; c2014 [cited 2014 Dec 17] Available from: http://www.hca.wa.gov/hta/Pages/index.aspx
5. Centers for Medicare and Medicaid Services. Medicare Program; revised process for making Medicare national coverage determinations. Fed Regist. 2003;68(187):55634-41.
6. Neumann PJ, Tunis SR. Medicare and medical technology-the growing demand for relevant outcomes. N Engl J Med. 2010;362(5):377-9.
7. Neumann PJ, Chambers J. Medicare's reset on "coverage with evidence development." Health Affairs Blog [blog on the Internet]. 2013 Apr 1 [cited 2014 Dec 17]. Available from: http://healthaffairs.org/blog/2013/04/01/medicares-reset-oncoverage-with-evidencedevelopment/
8. Chambers JD, Morris S, Neumann PJ, Buxton MJ. Factors predicting Medicare national coverage: an empirical analysis. Med Care. 2012; 50(3):249-56.
9. CMS.gov. National Coverage Determinations (NCDs) alphabetical index [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2014 Dec 17]. Available from: http://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
10. Neumann PJ, Kamae MS, Palmer JA. Medicare's national coverage decisions for technologies, 1999-2007. Health Aff (Millwood). 2008;27(6): 1620-31.
11. Chambers JD, May KE, Neumann PJ. Medicare covers the majority of FDAapproved devices and Part B drugs, but restrictions and discrepancies remain. Health Aff (Millwood). 2013;32(6):1109-15.
12. Neumann PJ, Divi N, Beinfeld MT, Levine BS, Keenan PS, Halpern EF, et al. Medicare's national coverage decisions, 1999-2003: quality of evidence and review times. Health Aff (Millwood). 2005;24(1):243-54.
13. Centers for Medicare and Medicaid Services. Guidance for the public, industry, and CMS staff: National Coverage Determinations with data collection as a condition of coverage: coverage with evidence development [Internet]. Baltimore (MD): CMS; 2006 Jul 12 [cited 2014 Dec 17]. Available from: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/ced.pdf
14. Health Care Financing Administration. Medicare program; criteria for making coverage decisions. Fed Regist. 2000;65(95):31124-29.
15. Neumann PJ, Chambers JD. Medicare's enduring struggle to define "reasonable and necessary" care. N Engl J Med. 2012;367(19):1775-7.
16. Chambers JD, Neumann PJ. Listening to Provenge-what a costly cancer treatment says about future Medicare policy. N Engl J Med. 2011;364(18):1687-9.
17. Chambers JD, Neumann PJ, Buxton MJ. Does Medicare have an implicit cost-effectiveness threshold? Med Decis Making. 2010;30(4):E14-27.
18. Carlson JJ, Sullivan SD, Garrison LP, Neumann PJ, Veenstra DL. Linking payment to health outcomes: a taxonomy and examination of performance-based reimbursement schemes between healthcare payers and manufacturers. Health Policy. 2010;96(3):179-90.
19. Tunis SR, Berenson RA, Phurrough SE, Mohr PE. Improving the quality and efficiency of the Medicare program through coverage policy: timely analysis of immediate health policy issues [Internet]. Washington (DC): Urban Institute; 2011 Aug [cited 2014 Dec 17]. Available from: http://www.urban.org/uploadedpdf/412392-Improving-the-Medicare-Program-Through-Coverage-Policy.pdf
20. CMS.gov. Draft guidance for the public, industry, and CMS staff: coverage with evidence development in the context of coverage decisions [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; 2012 Nov 29 [cited 2014 Dec 17]. Available from: http://www.cms.gov/medicare-coverage-database/details/medicare-coveragedocument-details.aspx?MCDId=23
21. Daniel GW, Rubens EK, McClellan M. Coverage with evidence development for Medicare beneficiaries: challenges and next steps. JAMA Intern Med. 2013;173(14):1281-2.
22. Jacques L. Testimony of Louis Jacques, MD; senior VP and chief clinical officer, ADVI; before the U.S. House of Representatives Energy and Commerce Subcommittee on Health Hearing: 21st century cures: barriers to ongoing communication and evidence development [Internet]. Washington (DC): House of Representatives; 2014 Jul 22 [cited 2014 Dec 17]. Available from: http://docs.house.gov/meetings/IF/IF14/20140722/102524/HHRG-113-IF14-Wstate-JacquesL-20140722.pdf