Formulating Coverage Policy for Adjunctive Technologies

1
Formulating Coverage Policy for Adjunctive
Technologies

• Eric Baugh, M.D.
• Senior Vice President, Medical Affairs, Care
  First, Blue Cross and Blue Shield

2
TEC Assessments Provide Information

• TEC assessments provide scientific information to
  users, including all BCBS Plans
• TEC used by health plans as one resource in
  developing coverage policy
• BCBS Plans are autonomous independent companies

3
Local Policy

• BCBS Plans rely on committees comprised of local
  participating physicians, academic experts, and
  Plan staff to review evidence and recommend
  medical policy
• Each Plan formulates its own policy

4
Medical Policy - The foundation upon which is
built
Claims Adjudication Policy Written or automated
program or protocols providing controls to
appropriately pay claims for services

• Guideline to accurately process a claim based on
  Medical Policy
• Tool for Claims Examiners and Customer Service
  Representatives.
• On-line review of claims for processing.
• Goal Company-wide consistency

• Influenced by
• Medical Policy
• Appropriateness of Medical Care
• Benefits

Utilization/ Case Management
Benefit Contractual services provided to
implement Medical Policy

• Influenced by
• Medical Policy
• Legislation
• Regulatory requirements
• Sales/Marketing
• Cost of Care

• Competitive Analysis
• Medical sign-off
• Legal sign-off
• Marketing/Sales sign-off
• Executive sign-off

Quality Medical Care

• Right Care
• Right Time
• Right Provider
• Right Setting
• Right Cost

Medical Policy A prudent plan or course of
action or guiding principle reflecting community
standards for diagnosis, treatment and care
to 1. Promote health or wellness, prevent
illness 2. Facilitate early detection of illness
or disease, restore function 3. Promote
monitoring of patient health status 4. Afford
opportunity for best medical outcome 5. Promote
quality medical care

• Technology Assessment FDA Approval
• Credentialed Physicians PT/Technology
  Assessment Committee
• Medical Community Standard of Care
• Current Medical Literature

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In-Puts to Medical Policy

• Contractual Definitions and Benefit Package
• Standard of Review
• Process for making and reconsidering coverage
  decisions- evidence-base and standards of high
  quality practice
• TEC assessments one resource

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Medical Policy for Adjunctive Technology

• Clinical benefit limited to subset of the
  population
• Coverage approved for members with specific
  indications, risk factors, or prior treatment
  history

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Medical Policy for Adjunctive Technology contd

• Coverage could be limited to specific settings or
  in context of clinical trial
• Example MRI covered for detection of occult
  breast cancer in women with cancerous lymph node
  and negative mammogram

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Claims Adjudication Process

• Protocols to implement medical policy
• Prior-Authorization
• Post-Service Claims Edits
• Retrospective Reviews

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Individual Review of Service Request

• Highly specific coverage criteria implemented on
  case-by-case basis
• Clinical reviewer at Plan obtains additional
  information from physician
• Burdensome to clinician, member, and Plan
• Plan considers time and cost of implementing
  coverage restrictions

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Retrospective Review

• Look at claims experience to gauge
  appropriateness of use
• Volume of claims should be small with limited
  indications
• Use to monitor up-take of guidelines and
  education through physician newsletters

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Payment Policy

• Level of payment for new service
• Based on cost
• Based on comparable service
• Option pay for new technology with equal benefit
  at same level as older technology?

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Medical Policy

• SELECTION CRITERIA FOR POLICY DEVELOPMENT
• HI VOLUME AND OR COST
• HEIGHTENED PUBLIC INTEREST OR CONTROVERSY
• AVAILABILITY WITHIN LOCAL MEDICAL COMMUNITY
• POTENTIAL/KNOWN OVERUTILIZATION AND OR ABUSE
• POTENTIAL FOR LITIGATION
• POTENTIAL / ENACTED LEGISLATION
• CHANGE FROM EXPERIMENTAL OR INVESTIGATIONAL
  

• ACCEPTANCE CRITERIA FOR NEW TECHNOLOGY OR NEW
  APPLICATION
• APPROVAL BY REGULATORY BODIES I.E. FDA/BCBSA TEC
• SCIENTIFIC EVIDENCE BASED OUTCOME STUDIES
• IMPROVEMENT TO HEALTH OUTCOME OUTWEIGHS HARMFUL
  EFFECT
• MUST BE AT LEAST AS BENEFICIAL AS ESTABLISHED
  ALTERNATIVES
• OUTCOME MUST BE ATTAINABLE OUTSIDE
  INVESTIGATIONAL SETTING

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Definitions

• COSMETIC
• PRIMARY INTENT OF IMPROVING
• APPEARANCE.
• NOT RESTORING BODILY
• FUNCTION CORRECTING
• DEFORMITY RESULTING
• FROM DISEASE, TRAUMA,
• OR PREVIOUS THERAPEUTIC
• INTERVENTION

• MEDICAL NECESSITY
• COMMONLY RECOGNIZED
• APPROPRIATE IN TREATMENT
• FOR DIAGNOSIS
• WITHIN THE STANDARD OF
• GOOD MEDICAL PRACTICE

• EXPERIMENTAL/INVESTIGATIONAL
• SERVICE OR TECHNOLOGY IN DEV-
• ELOPMENTAL STAGE OR TESTING
• DOES NOT HAVE FINAL REGULA-
• TORY OR GOVERNMENTAL APPROVAL.
• SCIENTIFIC EVIDENCE NON-
• CONCLUSIVE REGARDING OUT COMES
• EVIDENCE DOES NOT DEMONSTRATE
• NET IMPROVEMENT ON OUT COMES
• TECHNOLOGY NOT AS BENEFICIAL
• AS ESTABLISHED ALTERNATIVES

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Clinical Utility Unknown

• New technology under evaluation in clinical
  trials
• Clinical utility yet to be determined
• By definition, technology is investigational
• Contingent coverage- pay while trial is underway
• Eliminate coverage if utility not demonstrated

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Clinical Trial Mandate

• CareFirst mandated to pay for clinical trials of
  technologies for serious and life-threatening
  conditions in Maryland
• ABMT for high risk and metastatic breast cancer
• Trials did not demonstrate net health benefit
• Coverage ended after trials closed

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Health Care Policy Department
Legislative Regulatory Bodies
CareFirst Members
Health Care Policy
Department
Community Physicians/Providers Hospitals
CareFirst Staff
Claims Adjudication Policy
Benefit Design Inclusion
Technology Assessment Committee