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Who is “The Decider”?

November 14, 2012

With all the local and national discussions currently going on about health care quality and cost, it would make sense that whoever is paying the bills knows what they’re getting.  So it was with some astonishment that I recently learned in an issue brief put out by the American Academy of Actuaries that “…a large share of services provided to patients and reimbursed by insurers has no underlying evidence base”.   No underlying evidence base.  Whaaaaa???

How does an insurer decide whether to cover a new technology or treatment?1. The insurance company may subscribe to the services of “technology asessment organizations”.  2. The insurer may perform their own analyses.  3. They may do a little of both.  This kind of makes sense except that the problem with new technology is that it’s new.  Hasn’t been studied enough.  The insurance companies are looking for “proven benefit” but the data isn’t there yet.

Medicare is even worse.  While they may use technology assessment organizations,  they have alot of red tape added to that.  Did you know that Medicare processes claims through regional intermediaries in the form of  physician committees that make local coverage determinations?  Did you know that these committees are not obligated to make use of evidence-based technology assessments, but can conform to generally accepted regional practice patterns and professional experience?  That’s like asking the president of Pepsi to choose his own soft drink.  Of course he’s going to choose in his own financial interests.  Physicians will do the same, being human and all.  Take the Robot, for instance.  Anyone who reads this blog knows how I feel about the robot.  It’s expensive and hasn’t been shown yet to be of “proven benefit”.  But 80% of prostates in Boston are taken out robotically.  So what do you think the physician committee is going to say about covering robotic surgery?  They’re going to choose Pepsi every time.


From → Health Insurance

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