Title: Role of the Payer in Establishing Community Health Policy: The Case of Emerging Medical Technologies and "Medical Policy"
Author:
Section/SPIG: Community Health Planning and Policy Development
Issue Date:
Introduction
Community health planners, researchers and local health care advocates are all well aware of the traditional mechanisms by which health policy is determined. These range from open political processes and public forums to the potential impact of internal governmental staff, to the lobbying activities of physicians and health care organizations. Philanthropists and major foundations also have a significant role within local health care policy, with their scope of influence frequently integrated with local political engines. These activities comprise the mortar that occupies the varying spaces left between the masonry of state and federal mandates.
The role of the health insurer is rarely cited for its impact upon community health policy, yet it can rival the region’s health care providers as a significant policy influence. The payer is in the unique position of having well-defined, and often conflicting, contractual obligations with service providers, group insurance purchasers (including state/federal government), individual subscribers & patients, state & federal insurance regulators and stockholders. Within this context and under the influence of these customers, the payer has the responsibility to determine whether they will pay for thousands of medications and treatment technologies.
Under most conditions, this dilemma is appropriately resolved by allowing the treating physician to make the determination of efficacy. However, in the case of expensive, emerging medical technologies, payment decisions include many factors other than the treating physician’s recommendation. The review mechanisms and the guidelines for this process vary by payer, and are established as the “Medical Policy” for the plan. Payers with a dominant local market share become quasi public health agencies, able to dramatically influence patterns of care based upon these patterns of payment.
The Need for “Medical Policy”
Recent advances in chemotherapy and radiotherapy for oncology patients, genetically engineered drugs, artificial body parts and telemedical surgery have created an even greater burden on the payer to stay appraised of new health care technology. Increasingly, the lines between “investigational” and “state-of-the-art” are blurred, and are strongly influenced by market forces, investors, committed researchers and a public hungry for more effective health care. Appropriate monitoring of the efficacy of emerging technologies should include:
- Definition of the stage of clinical refinement for the technology.
- Does the technology provide an appreciable improvement over other interventions?
- Does the technology address an unmet need?
- How do similar technologies compare from a benefit/cost standpoint?
- Does the technology reasonably provide a therapeutic benefit to the specific patient in question?
A regional health insurer is typically uninterested in operationally addressing these complexities and unwilling to support the cost of necessary infrastructure. Even with a comprehensive, clinically sound technology assessment program, each health insurer is still faced with physician and consumer perception that the process is self-serving and with minimal objective value. There also is rarely a cogent rationale to have significant differences between payers concerning medical policy, unless that difference is due to an insurer’s marketing schema concerning more liberal/conservative coverage strategies (e.g., alternative medicine) or for the identification of medical technology assessment as an added-value “core competence” within their marketing portfolio.
The responsibility of the payer to develop medical policy related to emerging technologies must be addressed in a comprehensive manner, which both protects the patient and also recognizes the payer’s obligations to provide a cost-efficient health insurance product. And with rapid insurance market consolidation, there is a decreasing likelihood that the local market will be able to engage in a constructive dialog with the payer concerning the payer’s rationale for coverage of various advanced technologies.
Currently, each payer faces a “build versus buy” decision, which respect to medical policy (the Blue Cross Blue Shield Association is the most common vendor in this regard). Outside of state legislated mandates and Medicare + Choice requirements, each payer is provided significant latitude in the development of their Medical Policies (traditional Medicare allows its fiscal intermediaries to determine Medical Policy on their behalf, creating inconsistencies in payment policy on a national level). And unlike the statement of benefits, plan inclusions and exclusions which are required disclosures to each subscriber, medical policies are never disclosed to subscribers at time of enrollment. Subscribers only learn about the plan’s medical policy from their physician, if their prescribed treatment is not a currently covered service.
Balancing Access, Safety and Economics
An effective balance must be struck within each market for each payer concerning the responsibilities and obligations listed above. It is my position that the core focus of this balance should be to serve the best medical interest of the identified patient, being respectful of his/her individual desires. The health insurer should also recognize that the vast majority of all clinical cases will not create a situation of such dispute, as may arise in the case of use of emerging medical technology. When the patient’s best interest is paramount, the health plan should be able to effectively balance the following:
Obligation to Patients
- Protect patient from harm
- Provided medically related services as contracted
- “Enable” professionals and service vendors to provide require interventions
- Provide clinically credible, objective mechanism to review appropriateness of care
Obligations to Health Care Providers
- Facilitate physician-patient relationship
- Support physician or caregiver with scientifically based information and education
Technology Considerations
- Provided mechanism to proactively review medical technology innovations
- Allow patient to access new technology based upon clinical need and scientific efficacy
- Develop flexible, appropriate payment methodologies for new technologies
- Monitor provider use of new technology and provide medically appropriate guidelines for use. Insure that technology is not simply a revenue enhancement strategy, with negligible patient benefit
These obligations are reasonably similar for all payers, including Medicare and Medicaid, and also apply to ERISA-exempt, self-insured companies. They act to address the potential conflict between a patient’s need to access new treatments or tests and the obligation of the health plan to protect the patient’s interest within medically appropriate use of technology. What this does not address, however, is a mechanism to obtain the objectivity in technology assessment, patient-specific case review and availability of such a credible service for all payers within a market.
I would be very interested in your thoughts concerning this issue and any potential remedies to some of the problems which I have described. I will be developing a more detailed research proposal on this topic, using the case for coverage of intensity-modulated radiotherapy (IMRT) to highlight salient issues. Potential collaborators &/or students who would like some experience in policy research would be welcomed.