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COPYRIGHT 2004 Eli Research, Inc.
This is the first in a Perspectives series on technology-coverage issues.
It's an old war. On one side, health-care companies, clinicians, and patients push for wider access to new technologies. Across the battlefield, payers and many analysts argue for a more measured approach, one that takes into account the proven value and cost-effectiveness of new methods as well as their potential downsides.
As health spending rises and the post-marketing period turns up more deficiencies and even dangers in once-heralded products, such as the arthritis drug Vioxx and hormone replacement therapy, the battle is heating up again. Getting evidence before a technology proliferates into populations that are unlikely to benefit from it is a key goal of Centers for Medicare and Medicaid Services clinical officers, CMS staff and other analysts suggested at an Oct. 21 forum sponsored by Duke University and the Health Strategies consultancy.
* Who needs formal coverage decisions, anyway? Those who produce new medical technologies would prefer it if payers trusted doctors' judgments about what works and simply paid for what the doctor orders.
Nevertheless, all insurers set some rules about what services are covered, i.e., eligible for payment, explains Perry Bridger, director of Health Strategies' reimbursement practice. Basic coverage guidelines, which for private insurers are usually outlined in contracts, generally indicate that a plan will pay for safe and effective treatments that are appropriate for a patient.
Given the huge range of health-care products and services, insurers don't issue specific guidelines in every area, but "payers often institute coverage criteria to insure appropriate utilization," Bridger says.
For Medicare, Food and Drug Administration approval is usually a requirement before...
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