Health plans' coverage determinations for technology-based interventions: the case of electrical bone growth stimulation.

OBJECTIVES: To determine (1) whether commercial health plans' coverage criteria for a costly technology-based medical intervention are consistent with recent clinical effectiveness evidence, (2) whether medical directors adhere to planwide coverage criteria when making coverage determinations for individual patients, and (3) if any organizational characteristics are associated with having more stringent coverage criteria or making more frequent coverage denials. STUDY DESIGN: Case-based survey of medical directors of US commercial health plans. METHODS: A close-ended survey was mailed to 346 medical directors meeting eligibility criteria, asking about the criteria specified in their plans' coverage policies for electrical bone growth stimulation (EBGS) and whether they would cover this intervention for a hypothetical patient with abnormal union of long-bone fracture. RESULTS: Responses from 228 (66%) of the 346 directors indicated that approximately 72% of plans have a formal coverage policy for EBGS for long-bone fractures. More than 30% of plans specify that longer than 4 months must elapse before EBGS is attempted, although clinical studies do not support absolute waiting times. Directors of approximately 61% of plans with policies requiring extended waiting periods would nevertheless authorize EBGS for patients who did not meet this criterion. CONCLUSIONS: Health plans apply varied criteria in coverage policies for technology-based treatments such as EBGS, but do not always adhere to stated criteria when determining coverage for individual patients. For-profit status, accreditation status, geographic location, and size of plan are not associated with being more or less likely to authorize EBGS.

Managed care and integrated health care.

Managed care and integrated care may be viewed as stages in the evolution of the U.S. health care system. The authors discuss the essential characteristics of an integrated delivery system, including patient satisfaction, maintenance of clinical skills, cost-effective practice, and professional reputation.

Are the Twin Cities a Stage V marketplace?

The Twin Cities continues to be an outstanding laboratory for discovering what could be the future in many other markets. Over the last year or two it has been the site of massive consolidation among hospitals, physicians and health plans. Even as the entire infrastructure for healthcare financing and delivery has changed, the state has turned in a good performance in comparison with national cost averages. It is hard to beat premium levels that are 25%-35% lower than national benchmarks. And, these have been achieved by the marketplace, not by government. Nevertheless, employers aren't completely satisfied and the sources of discontent are very instructive. The natural course of market change throughout the country is consolidation from many fragmented competing groups down to a handful of large integrated systems. From an employer/consumer perspective, this natural evolution will reduce competition, concentrate power, eliminate choice, weaken the employer's negotiating leverage, discourage innovation, and reduce the responsiveness and sensitivity to customer service needs. Strategies have to be devised by those engaged in integrated health systems development to counter the perception that consolidation is only an attempt to grab market share. True integration should produce demonstrable improvements in the quality, coordination and delivery of care. But, the trick is understanding the employer and consumer perspective on "improvements". The financing and delivery of healthcare has literally been hidden inside a "black box" for as far back as anyone can remember.(ABSTRACT TRUNCATED AT 250 WORDS)