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Denying Coverage = Good?

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In the heated debate before Congress passed the Affordable Care Act (“health care reform”), starting in the summer of 2009, there were persistent rumors that the bill would create “death panels” to decide whether certain patients should not be treated due to expense. While the rumor was thoroughly debunked, it did lead to Congress removing a provision that would have authorized Medicare to cover voluntary end-of-life planning consultations with a counselor. And the rumor may be one reason the law took a conservative approach toward comparative effectiveness research, examining which treatments work well and which ones don’t.

As a recent article at Kaiser Health News notes, the law established the Patient-Centered Outcomes Research Institute, or PCORI, an independent organization charged with comparing the treatments available for health conditions and issuing recommendations. Its recommendations are nonbinding, although any private insurer can base insurance coverage decisions on PCORI recommendations, and Medicare can do so but only after a drawn-out process that includes public comment. The article notes, however, that despite evidence that they offer few benefits and may even cause harm, certain procedures are still covered by Medicare and most private insurers because doctor and patient groups protested against eliminating coverage. These treatments include vertebroplasty (the injection of medical cement into spinal compression fractures) and the drug Avastin for breast cancer, whose approval for that form of cancer the FDA withdrew last year. The drug can, however, still be used “off-label” for breast cancer at the discretion of doctors.

Opponents of restricting insurance coverage based on comparative effectiveness research, including many doctors and patient advocates, note that studies are often contradictory — one might show a treatment to be useless, while another might show it to have benefits. Only after years of research, they say, and sometimes not even then, can a verdict be reached. Advocates of coverage restrictions note that doctors often make treatment decisions based on habit and the advice of colleagues rather than objective research, and that expensive, “cutting-edge” procedures may be prioritized simply because they are new. Basing coverage decisions more aggressively on research, they say, will lead to both better patient outcomes and lower health-care costs.

What do you think — what standard should be used to decide whether an insurance plan covers a medical treatment? Should the cost of a treatment play a role in that decision? Should public insurance, such as Medicare, be held to a different standard than private insurance plans? Can doctors be trusted to make treatment decisions based on research, or should insurance plans try to help guide their decisions? Leave a comment below!

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