GOVERNMENT & MEDICINE

New panel gives doctors a say about future Medicare benefits

Physician input is sought as HCFA embarks on a new, more public method for deciding which innovative treatments will be covered.

By Susan J. Landers, AMNews staff. Oct. 25, 1999. - Additional information.

Washington -- Shining some light into what long had been a dark regulatory corner, the Health Care Financing Administration recently began a new, more open process for making national Medicare coverage decisions.

Although the agency's national coverage policies affect only about 10% of decisions, the new process is at least "a step in the right direction," say many observers.

In an effort to gain the input of physicians, consumers and others before making its decisions, HCFA formed a Medicare Coverage Advisory Committee, consisting of six medical specialty panels organized roughly parallel to Medicare's benefit categories. It also established an executive committee.

Physicians fill the majority of committee chairs, and representatives from the durable medical equipment industry and consumer groups hold one seat each per panel as well as seats on the executive committee. One of the panels held its first meeting last month.

"We are open for business," said Grant Bagley, MD, director of HCFA's coverage and analysis group.

The new process was developed in response to long-standing criticism that HCFA's decision-making process was unclear and closed to public scrutiny. Approval for innovative treatments for Medicare beneficiaries also appeared to lag well behind approval rates in the private sector.

AMA Trustee William G. Plested, MD, emphasized to a congressional panel last spring the importance of ensuring that Medicare patients have access to the "same clinically effective innovations in medical practice and technology that we are able to offer our privately insured patients."

Although HCFA still will make the final decisions regarding coverage, the new advisory committee is charged with analyzing available scientific and medical information and making recommendations for covering specific items and treatments.

This evidence-based approach is strongly favored by the AMA and other medical specialty societies.

"Coverage decisions should be based on evidence of clinical effectiveness obtained from medical literature and consultations with practicing physicians," AMA Trustee J. Edward Hill, MD, told the Practicing Physicians Advisory Council last month.

In the spotlight

HCFA's new process takes place, for the most part, in public.

The drugs, biologics and therapeutics panel held a two-day hearing in September in Baltimore, at which about 200 people were present until hurricane Floyd's approach cut into attendance.

After analyzing medical evidence and hearing testimony from patients and physicians, the panel recommended that Medicare provide coverage for high-dose chemotherapy and bone marrow transplantation for the treatment of multiple myeloma, an illness that afflicts about 13,000 Americans each year.

HCFA says it will decide no later than Nov. 14 and that the decision will be posted on the agency's Web site, joining the panels' meeting schedules and agendas there -- another concession to openness.

Although the agency selected the topic for the first panel discussion and recommendation, physicians and others are encouraged to forward formal requests to HCFA for a coverage decision.

The other five panels cover: diagnostic imaging, laboratory and diagnostic services, medical and surgical procedures, durable medical equipment, and medical devices and prosthetics. The laboratory and diagnostic services group will meet Nov. 15-16.

Two members of each panel serve on the overarching executive committee that will provide oversight, develop guidance documents and advise HCFA on the implementation of the panels' recommendations.

"The medical and scientific communities have a great deal to offer the agency as it decides which treatments, procedures and devices merit coverage," said Ronald M. Davis, MD, one of the executive committee's members. Dr. Davis, who is director of the Center for Health Promotion and Disease at the Henry Ford Health System in Detroit, is also a member of the medical devices and prosthetics panel.

Although HCFA won't be bound by the advisory group's recommendation, Dr. Davis hopes the advice will be followed "unless there are extraordinarily compelling reasons not to."

The agency's new coverage process involves key Medicare stakeholders, such as physicians and consumers, at a much earlier stage than in the past, Dr. Davis said. It also presents the opportunity for the various medical specialty societies and the AMA to exercise greater influence over the process, he added.

HCFA's Dr. Bagley urged physicians to take advantage of the new process to make formal requests for national coverage decisions. He pointed out that the medical societies were well-placed to supply the medical evidence that supports the efficacy of a new treatment, procedure or device.

"It's critical that the specialty societies weigh in with their opinions both during and after the process," Dr. Bagley said.

"Pat HCFA on the back" if you think the right coverage decision was made, he said, or submit a request to reconsider the decision if the opposite is true.

Additional improvements needed

Although many believe HCFA is moving in the right direction with its new process, some urge additional steps:

• The AMA recommends that HCFA develop coverage decision standards that would apply to the 90% of decisions made by local carriers who currently rely on their own policies. The goal is to achieve greater uniformity in Medicare coverage across the country.
• Consumer representative Sally Hart, a staff attorney with the Center for Medicare Advocacy, based in Willimantic, Conn., questioned whether consumers would avail themselves of the opportunity to testify before a panel. Hart is a consumer representative on the advisory committee's diagnostic imaging panel.

"Most consumers don't get interested in the issues until they are personally denied coverage," she noted.

• Former HCFA attorney Terry Coleman said that, although the new process is an improvement over what existed before, he is waiting for the publication of HCFA's criteria for coverage decisions. "That is the more important event," he said.

HCFA published a controversial proposal governing coverage decisions 10 years ago, noted Coleman, but it was never finalized.

Dr. Bagley described the agency's new process as the reopening of the debate, but this time in "more manageable pieces that we could handle."

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