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according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.
At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.
“It is very hard to know at the beginning of coverage that something is going to be low value,” MedPAC commission member Kathy Buto, former vice president of global health policy at Johnson & Johnson, noted. “It may be covered for something narrow for which it is high value and then spreads. It’s important to have those kinds of tools once technologies and procedures are covered to be able to actually monitor what is going on and assess.”
But, she added, the Centers for Medicare & Medicaid Services needs to do more to routinely reexamine its coverage decisions.
Ms. Buto noted that noncoverage decisions are rarely issued and suggested that “there is an opportunity for us to take a look at whether we would advise CMS to take a look at using more of those tools more aggressively.”
Paul Ginsburg, PhD, commissioner and senior fellow in economic studies at the Brookings Institution, Washington, suggested that, for any new procedure or drug, initial coverage is always provisional for a certain length of time, which would force CMS to revisit coverage decisions.
“If there is no evidence, the coverage ends,” Dr Ginsburg said. “If there is positive evidence, the coverage proceeds.”
However, as commissioner Rita Redberg, MD, of the University of California, San Francisco, said of CMS, even with tools to cut coverage, its hands may be tied by outside forces. “CMS needs a lot more political cover.”
Dr. Redberg noted that there was extensive lobbying of local carriers, and within 6 months, despite the lack of evidence, everyone was covering cardiac CT.
“A few years later, CMS tried to walk back the coverage because it was just hemorrhaging money for cardiac CT, but there was no chance because it was a capital investment,” she added. “Even when there are restrictions on coverage, CMS doesn’t enforce them.”
Ms. Buto also raised the issue of how much influence CMS has over Medicare Part D prescription drug plan sponsors’ coverage decision policies, but suggested CMS could play a larger role in that.
Commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, suggested that, “We need to do more from a Part D perspective to allow plans to manage drug coverage more aggressively and in line with the commercial space. CMS has handcuffed them,” noting that FDA approval, regardless of value, generally means Medicare coverage.
Commissioner Jack Hoadley, PhD, of Georgetown University in Washington, cautioned that any discussion on these or possibly other tools needs to take into account the needs of those who will legitimately benefit from some of the low-value services so they do not inadvertently prevent access for those patients.
At press time, MedPAC had not scheduled a vote on specific recommendations to address low-value care.
according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.
At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.
“It is very hard to know at the beginning of coverage that something is going to be low value,” MedPAC commission member Kathy Buto, former vice president of global health policy at Johnson & Johnson, noted. “It may be covered for something narrow for which it is high value and then spreads. It’s important to have those kinds of tools once technologies and procedures are covered to be able to actually monitor what is going on and assess.”
But, she added, the Centers for Medicare & Medicaid Services needs to do more to routinely reexamine its coverage decisions.
Ms. Buto noted that noncoverage decisions are rarely issued and suggested that “there is an opportunity for us to take a look at whether we would advise CMS to take a look at using more of those tools more aggressively.”
Paul Ginsburg, PhD, commissioner and senior fellow in economic studies at the Brookings Institution, Washington, suggested that, for any new procedure or drug, initial coverage is always provisional for a certain length of time, which would force CMS to revisit coverage decisions.
“If there is no evidence, the coverage ends,” Dr Ginsburg said. “If there is positive evidence, the coverage proceeds.”
However, as commissioner Rita Redberg, MD, of the University of California, San Francisco, said of CMS, even with tools to cut coverage, its hands may be tied by outside forces. “CMS needs a lot more political cover.”
Dr. Redberg noted that there was extensive lobbying of local carriers, and within 6 months, despite the lack of evidence, everyone was covering cardiac CT.
“A few years later, CMS tried to walk back the coverage because it was just hemorrhaging money for cardiac CT, but there was no chance because it was a capital investment,” she added. “Even when there are restrictions on coverage, CMS doesn’t enforce them.”
Ms. Buto also raised the issue of how much influence CMS has over Medicare Part D prescription drug plan sponsors’ coverage decision policies, but suggested CMS could play a larger role in that.
Commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, suggested that, “We need to do more from a Part D perspective to allow plans to manage drug coverage more aggressively and in line with the commercial space. CMS has handcuffed them,” noting that FDA approval, regardless of value, generally means Medicare coverage.
Commissioner Jack Hoadley, PhD, of Georgetown University in Washington, cautioned that any discussion on these or possibly other tools needs to take into account the needs of those who will legitimately benefit from some of the low-value services so they do not inadvertently prevent access for those patients.
At press time, MedPAC had not scheduled a vote on specific recommendations to address low-value care.
according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.
At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.
“It is very hard to know at the beginning of coverage that something is going to be low value,” MedPAC commission member Kathy Buto, former vice president of global health policy at Johnson & Johnson, noted. “It may be covered for something narrow for which it is high value and then spreads. It’s important to have those kinds of tools once technologies and procedures are covered to be able to actually monitor what is going on and assess.”
But, she added, the Centers for Medicare & Medicaid Services needs to do more to routinely reexamine its coverage decisions.
Ms. Buto noted that noncoverage decisions are rarely issued and suggested that “there is an opportunity for us to take a look at whether we would advise CMS to take a look at using more of those tools more aggressively.”
Paul Ginsburg, PhD, commissioner and senior fellow in economic studies at the Brookings Institution, Washington, suggested that, for any new procedure or drug, initial coverage is always provisional for a certain length of time, which would force CMS to revisit coverage decisions.
“If there is no evidence, the coverage ends,” Dr Ginsburg said. “If there is positive evidence, the coverage proceeds.”
However, as commissioner Rita Redberg, MD, of the University of California, San Francisco, said of CMS, even with tools to cut coverage, its hands may be tied by outside forces. “CMS needs a lot more political cover.”
Dr. Redberg noted that there was extensive lobbying of local carriers, and within 6 months, despite the lack of evidence, everyone was covering cardiac CT.
“A few years later, CMS tried to walk back the coverage because it was just hemorrhaging money for cardiac CT, but there was no chance because it was a capital investment,” she added. “Even when there are restrictions on coverage, CMS doesn’t enforce them.”
Ms. Buto also raised the issue of how much influence CMS has over Medicare Part D prescription drug plan sponsors’ coverage decision policies, but suggested CMS could play a larger role in that.
Commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, suggested that, “We need to do more from a Part D perspective to allow plans to manage drug coverage more aggressively and in line with the commercial space. CMS has handcuffed them,” noting that FDA approval, regardless of value, generally means Medicare coverage.
Commissioner Jack Hoadley, PhD, of Georgetown University in Washington, cautioned that any discussion on these or possibly other tools needs to take into account the needs of those who will legitimately benefit from some of the low-value services so they do not inadvertently prevent access for those patients.
At press time, MedPAC had not scheduled a vote on specific recommendations to address low-value care.
REPORTING FROM MEDPAC