Coverage Policy Provocateurs

Anyone curious about potential future directions in Medicare coverage policy, or simply looking for a detail-packed treatment of this complex subject, can check out the topic via a newly posted Urban Institute report, which includes as authors former CMS coverage policy officials Sean Tunis (pictured below) and Steve Phurrough.

The report rattles around the known world of coverage and evidence, with attention to history and the authors’ own perspectives on what’s worked and what hasn’t. As one measure of the report’s scope, the assorted policy points are illustrated by health care interventions that range from PET, to implantable defibrillators, to Provenge, to alternative prostate cancer treatments, to ESAs, and on and on. The footnotes and cited sources are alone worth the price of admission.

Most provocative are the policy prescriptions, which, in the view of the authors, spring from the role of technology as “the leading cause of health spending.” Seeking to install coverage policy as one pillar in a new conception of value-based purchasing, the report calls for, among other steps, changing the Medicare statute to effect three changes, which, in ascending levels of policy departure, are as follows:

  • Establish explicit legal authority for CMS to undertake coverage with evidence development.
  • “[R]estore and expand” Medicare authority to apply Least Costly Alternative policies.
  • “Allow Medicare to explicitly consider costs as part of the national coverage process.”

Depending on your perspective, these and other recommendations may seem policy nirvana, the ultimate chamber of horrors, or something in between. But whatever your view, give the authors their due: They’ve taken on a nuanced and controversial subject, and they haven’t pulled their punches.