Tuesday, June 19, 2018

New 70-Page Guide to Coverage Issues at Medicare (MedPAC 2018, Chapter 10)

Every June, the federal advisory body MedPAC provides a report to Congress on Medicare policy/payment issues. 

This year, Chapter 10 is a 70-page overview of the LCD and NCD processes, heavily laced with up-to-date charts and footnotes.   Yes, for health policymakers, it's Christmas-Come-Early.   In addition to providing a good learner's guide to CMS coverage, the chapter gives a lot of attention to issues related to low-value care and ways that CMS might, possibly, use new policy tools (like pre-authorization).

Find the chapter here.

All the familiar topics old and new are described, including differences between LCDs and NCDs, Medicare's variable use of Coverage with Evidence Development, Parallel Review, and attempts to bring more cost-effectiveness into Medicare decisions.   Medicare's 1989 and 2000 efforts to "define reasonable and necessary in regulation" are duly memorialized.  (For even more, see Susan Foote's 2002 article "regula mortis," here.)

The MedPAC clearly tries to be fair-handed; after discussing CMS's two examples of Parallel Review, they also cite a discontented viewpoint:  Podemska-Mikluch (2016) FDA CMS Parallel Review: A failed attempt at spurring innovation.  George Mason University.

MedPAC provides an interesting table at 10-2, which shows that average NCDs per year (new or reconsidered) ran  from 9/yr to 17/yr a decade ago, with as little as 81 days per year for implementation.   More recently CMS produced only 4 NCDs per year and with a timeline of 301 days for implementation.

MedPAC June 2018 Table 10-2, click to enlarge

Cases studies of "low value care" are: (1) proton beam therapy, (2) the gel ACTHar drug, and (3) the issue of earlier initiation of dialysis (earlier than 10ml GFR). 

Regarding ACTHar, they report that the great majority of docs prescribing it get goodies from the company (match up CMS ordering records with public data under Sunshine Act). 

They compare categories of low value care between MA and FFS plans.   The MedPAC authors close with a thorough discussion of new coverage and utilization management tools, such as clinical decision support and preauthorization, as well as a discussion of cost-benefit policy in law and of the Boston thinktank ICER.

There are several citations to works by past and present CMS leaders, such as:
  Daniel GW, Rubens EK, McClellan MM (2013)  Coverage with Evidence Development: Challenges and next steps.  JAMA Int Med 173:1281-82.
  Mohr PE & Tunis S (2010)  Access with evidence development: the US experience.  Pharmacoecon 28:153-62.
  Tunis S et al. (2011)  Improving the quality and efficiency of the Medicare program through coverage policy.  Urban Institute.
  Jensen T (2014)  CMS coverage perspective for diagnostic tests. (deck)  Here.
Not cited here but see similarly:
  Jensen T & Jacques LB (2011) Medicare coverage: Engaging on evidence.   Regen Med 6(6 Supp) 99-101.