As I wrote previously, the United Kingdom’s approach to health services coverage decisions offers a contrast to that in the U.S. The U.K.'s National Institute for Health and Care Excellence (NICE) makes coverage recommendations driven in large part by cost-effectiveness, but also considering other factors such as uncertainty, innovation, non-health outcomes, end-of-life considerations, and stakeholder perspectives on quality of life gains. And in the U.S.?
Well, the knock on the U.S. is that we cover treatments too readily, helping to support the application of costly health care technology even when it does little good. Moreover, we have very few institutions that systematically evaluate the strengths and limitations of coverage of various treatments. In this way, we're very different from the U.K.
But we don't have zero institutions. A recent article in Health Affairs by James Chambers and colleagues highlights one. Believe it or not, it's Medicare. The article focuses on Medicare's national coverage decisions (NCDs), finding the program has become more restrictive over time. Yes, there are things even Medicare won't cover.
Though speculative, the authors open their article suggesting we might take what's happened in Medicare as indicative of coverage in general.
Reports from the field suggest that it is becoming increasingly difficult to gain coverage and reimbursement for new medical interventions. [...] [V]arious trends indicate that coverage and reimbursement for new medical interventions are becoming more restrictive.
Thus, though most Medicare coverage decisions are made by regional contractors, NCDs may offer a window of coverage policies across insurers.
The authors related 213 coverage decisions made between 1999 and 2012 to type of evidence considered (e.g., randomized trials, other studies, clinical reviews and guidelines, professional society statements); to volume of evidence (e.g., frequency each type was used for each decision, number of patients included in relevant studies); and to consistency of evidence. Breaking that time span into four quartiles with roughly equal numbers of decisions, they found a downward trend in positive decisions (i.e., to cover a treatment). During the most recent quartile (March 2008-August 2012), about 32% of decisions were positive. During the first quartile (February 1999-January 2002) 80% were positive.
The authors also ran a supplemental analysis that included controls for the availability of alternative medical interventions and cost-effectiveness. The authors concluded that
national coverage determination decision making is consistent to an extent with the evidence base, in that coverage is associated with the included proxy variables that attempt to characterize evidence quality. [...] [W]e found that the availability of alternative interventions and the lack of an associated estimate of cost effectiveness decreased the likelihood of Medicare coverage—even though CMS does not formally consider cost-effectiveness evidence in national coverage determinations for treatment. However, it is notable that the magnitude of the ratio between cost and quality-adjusted life year—that is, the relative cost-effectiveness of the medical intervention—did not appear to influence coverage.
These findings echo a prior publication using NCD data from 1999 through 2007 (195 coverage decisions) that found that good or fair quality supporting evidence and presence of an alternative intervention was positively associated with coverage. But coverage was not associated with an estimate of cost-effectiveness.
For all that, it remains true that most Medicare coverage decisions are made by regional contractors, not at the national level. Moreover, as Nicholas Bagley wrote in an article in The Georgetown Law Journal, Medicare yields the vast majority of clinical decisions to physicians. Its modest number of NCDs don't exert much influence.
[T]here is suggestive evidence that Medicare contractors do not reliably enforce NCDs . For just one example, Medicare purports not to cover colonoscopies within ten years of a prior colonoscopy that revealed no abnormalities. Yet Medicare contractors deny only about two percent of claims for inappropriate, repeat colonoscopies.
Perhaps NCDs have trended toward evidence and greater restrictiveness. But their small number and lack of influence may render them relatively meaningless. The U.S. is very different than the U.K.
Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs or Boston University.