Gregory Przybylski, MD, gave a presentation titled "Payer Coverage Policies: Their Development, Evolution and the Influence of Professional Medical Association Recommendations" at the North American Spine Society Annual Meeting earlier this year. Dr. Przybylski is a spine surgeon with New Jersey Neuroscience Institute at JFK Seton Hall University and medical director at Cigna.
The key questions to consider when developing coverage policies include:
1. Are we spending too much? The United States spends more as a percentage of GDP than other developed countries, but there isn't a similar incremental increase in value based on spending.
2. Are we spending in the right places? This is where most of the cost and quality initiatives are focused to redistribute where money is spent.
3. Do we know what we are paying for? Outcomes research is focused on describing healthcare services, but there is still room for improvement because of the separation of cost data insurance companies have compared with the outcomes data physicians accumulate. "If we could share that data in some way perhaps better understanding of how to bend the cost curve could be achieved."
4. Do incentives promote quality care at an affordable cost? For years, healthcare operated in a fee-for-service model, incentivizing providers based on volume. Now, payers and health systems are transitioning to shared savings and value-based payments to emphasize patient outcomes and functionality over volume.
Insurers and providers are looking at accountable care organizations, bundled payments, episode grouping, broad networks with payer consolidation and narrow networks to turn the tide. There are payers also focused on utilization review to update coverage policies. Over time, NASS created committees to develop clinical guidelines based on evidence and coverage recommendations to influence how coverage policy decisions are made.
Coverage policy development focuses on new tests, procedures, devices, technologies with safety concerns, technology with clinical utility concerns, technology with a high level of interest and peer-reviewed scientific publications.
Over the past few years, spinal decompression frequency has been flat, growing no more than 5 percent each year and interbody fusion grew 10 percent to 20 percent per year, but around 2008 SI joint fusion increased substantially.
"When an economist sees information like this, they tend to examine if there is some sort of economic incentive that dries a frequency over its baseline. That's not always the case but it drives some introspection. For example, CMS, when they look at that kind of data, they are looking for frequency increases of only 10 percent per year for three years before they actually look for something."
The insurance companies have several steps for developing coverage policies, including examinations of:
• Peer-review publications
• Technology assessments
• PMA clinical practice guidelines
• Regulatory approval/FDA status
• External medical review
"Ultimately a decision of medical necessity is made based on generally accepted standards of care, what is clinically appropriate and considered effective, what is primarily for convenience and whether there is a less costly than an alternative. Finally, the outcome of this product ends up being a coverage policy that is submitted to all this different criteria."
The approval process takes a long period of time and professional medical association input is encouraged. Insurance company workgroups make these decisions and review them for annual updates based on new literature. The companies disseminate updates online and directly to providers. There is generally a notice period before this is implemented and an outreach to providers and professional medical associations.
"The bottom line is interface with our medical society and insurers have positive outcomes and can result in change. Coverage policies are just one tool for managing healthcare. Transparency is critical and shareholder input is valued."
However, the "experimental treatment" language in benefit plans could mean new technologies or procedures, and in some cases procedures covered for many years, aren't currently covered by the payer.
The language that benefit plans have includes three different categories: experimental, unproven or investigational. Dr. Przybylski defined the three categories as follows:
1. Experimental: Applying a technology someplace that hasn't been applied before.
2. Investigational: Performing procedures for which data is currently being accumulated.
3. Unproven: Technology when there is insufficient data to make a conclusion.
Insurance companies take several aspects of any procedure into account before moving between an "experimental" definition to accepted coverage.
"The fact that new technology is easier to look at in this way than something that has been covered for a long period of time and looking back retrospectively, vertebroplasty for example, was difficult not cover for certain indications. I think the level of evidence in peer review publications that have a PRCT has the greatest influence."