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U of M study: Medicare lacks tools, incentives to enforce evidence-based coverage policies
Date:10/31/2007

MINNEAPOLIS /ST. PAUL (October 31, 2007) According to new research at the University of Minnesota, Medicare lacks sufficient information in most cases to apply a policy and does not have the resources or incentives to acquire the information. Medicare appears reluctant to aggressively enforce policies that affect medical judgments, even if those decisions are inconsistent with scientific evidence.

By law, Medicare must pay only for items or services deemed reasonable and necessary. Medicare has developed scientifically sophisticated, evidence-based coverage policies to evaluate when selected medical procedures will be covered, and if so, describes specific clinical conditions and other factors necessary for payment. Medicare contractors, the private entities that process claims for payment, are directed to apply these policies to determine when to pay or deny a claim.

There has been much discussion among providers, payers, and policymakers to encourage evidence-based medicine as a means to improve quality and reduce costs, said Susan Bartlett Foote, J.D., M.A., the principal investigator, and University of Minnesota professor in the School of Public Healths Division of Health Policy and Management. Our research shows that there are considerable barriers to achieving that goal in Medicare.

The bottom line is that Medicare simply doesnt have the tools to make evidence-based medicine work, Foote said.

Policymakers assume that Medicares coverage policies change physician behavior. Our research shows that they dont.

Implementing coverage policies offers a promising way to reduce geographic variations and manage diffusion of technology. Unfortunately, despite Medicares great strides in the area of evidence development, we are falling short on the implementation side.

Foote also offers some solutions:

Improve information: Contractors must have all necessary clinical information to evaluate whether a claim is in compliance with the
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Contact: Nick Hanson
hans2853@umn.edu
612-624-2449
University of Minnesota
Source:Eurekalert

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