Navigation Links
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 policy. Policymakers should convene experts to redesign claims forms and coding, or other mechanisms to acquire supplemental information.

Align incentives: Contractors are rewarded for efficient low-cost claims processing, not for enforcement of coverage policies. Policymakers need to modernize the role of contractors to incent them to pay only for value.

Invest in compliance: Contractors need additional resources to request and review patient charts in the absence of information on the claim. A highly effective and visible effort is necessary to inform providers that policies will be enforced.

Improve education: Contractors must educate providers on the importance of coverage policies. Patients need better information so they know how the science affects them as well.

Foote concludes, Public and private payers are often reluctant to second guess doctors and other professionals. We have seen abuses where payers deny needed and necessary care. When Medicare was passed in 1965, professionals were assured that the program would not interfere with the practice of medicine. But Medicare is also directed not to pay for procedures unless they are reasonable and necessary. Theres an inherent tension between these goals. However, in an era of rising costs and questionable quality, we must refine tools to ensure that patients get care based on scientific evidence.


'/>"/>

Contact: Nick Hanson
hans2853@umn.edu
612-624-2449
University of Minnesota
Source:Eurekalert

Related medicine news :

1. Counter study: cholesterol drugs no good in preventing colon cancer
2. A strategic study: Soy diet makes heart disease to worsen in male mice
3. Bird Flu Pandemic Study: Clerical & Support Staff May Stay At Home
4. Study: Older Pancreatic Cancer Surgery Survivors Live Long
5. New Study: Pine Bark Significantly Reduces Endometriosis
6. Medicare Drug Deadline not to be extended
7. House heads for Medicare drug vote
8. New Medicare Plan - Mixed Reaction among Pharmacists.
9. Medicare Data would help in Drug Validation
10. Medicare Queries Expected To Increase Over Time
11. Medicare to cover services provided by rural health care personnels.
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:5/23/2017)... (PRWEB) , ... May 23, 2017 , ... ... Plastic and Reconstructive Surgeon Dr. Kevin Sadati, is pleased to announce a new ... building collagen and elastin in their face, neck, and body through a virtually ...
(Date:5/23/2017)... (PRWEB) , ... May 23, 2017 , ... ... availability of video chat as a standard feature on its secure clinical communication ... text to voice to video depending on the type and urgency of a ...
(Date:5/23/2017)... Segundo, CA (PRWEB) , ... May 23, 2017 ... ... braces can now receive treatment using the SPEED Systemâ„¢ Orthodontics, with or without ... respected orthodontist in El Segundo, CA, who is skilled in providing ...
(Date:5/22/2017)... (PRWEB) , ... May 22, 2017 , ... Patients who ... to receive relaxing sedation dentistry in Mt. Kisco, NY from Advanced Endodontics of Westchester. ... for a variety of treatments. One or more sedation methods may be recommended based ...
(Date:5/22/2017)... ... May 22, 2017 , ... “Homeostasis: The Journey of ... to live with Bipolar 1. Donald Rodriguez takes readers on a rollercoaster ride that ... the dead of winter and to a dark place where Donald considers suicide. ...
Breaking Medicine News(10 mins):
(Date:5/10/2017)... 2017 Radiology has become the number one ... also spiraled to the number one ranking as a ... ever before as the most complete and reliable method ... lower back pain an MRI may confirm a suspected ... resulting in entirely different treatment protocols.  In these circumstances, ...
(Date:5/9/2017)... WASHINGTON , May 9, 2017  Demonstrating ... the board of directors for the Pharmaceutical Research ... criteria for membership. Biopharmaceutical companies will now have ... in order to be eligible to join PhRMA. ... criteria, the board is sending a clear message ...
(Date:5/8/2017)... , May 8, 2017 MACRA replaces ... from fee for service reimbursement. Black Book Research crowdsource-surveyed ... 1.       The Market for MIPS Compliance Technology ... of physician practices with 3 or more clinicians seek ... by Q4. "Given the magnitude of the changes, the ...
Breaking Medicine Technology: