Medical Device Coverage: Do Private Payers Follow Medicare’s Lead?


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Perspectives on Medical Reimbursement

By JR Associates

When making decisions about medical device coverage, do private insurers take their cues from Medicare (CMS)? Not necessarily, according to a recent study published in the peer-review journal, Health Affairs.

According to the research abstract, an analysis of CMS national coverage decisions (NCDs) revealed that:

~50% were equivalent to corresponding private payer policies
~25% were more restrictive
~25% were less restrictive.

Therefore, researchers concluded that patients may have variable access to medical technology across Medicare and private plans — and that private payers do not necessarily follow CMS’s lead in coverage decisions.

However, as two of our firm’s consultants explained in a recent interview with Medical Device Daily, these conclusions may be invalid, because the study’s design is flawed.

In the article “Inside the Beltway: Study of Medicare, Private Payer Coverage Seen as Apple vs Orange” (available to the publication’s subscribers), JR Associates president Judy Rosenbloom and VP Global Health Policy Jo Ellen Slurzberg discussed these disconnects with regulatory affairs editor, Mark McCarty.

For example, the data collected is incomplete in several respects:

Some types of medical devices were not included in the analysis.
 Information from private payers who do not publish coverage policies (such as Kaiser Permanente) is also excluded.
 And as Jo Ellen explained, “We don’t know what they really looked at because they don’t say which coverage decisions they reviewed.”

Judy shared additional concerns. For instance, she noted that patient profiles can influence the alignment between private payers and CMS. “We do see private payers following Medicare when they have a Medicare-intensive patient population.” However, private payers aren’t legally required to respond to requests for coverage, the way Medicare does. This makes it difficult to determine if private payers are reacting to the same set of coverage requests as CMS.

Even the authors of the study acknowledge methodological weaknesses. In particular, they say they weren’t always able to establish the date of a private payer’s coverage decision, so they couldn’t be certain if the payer was acting independently or mirroring CMS.

These and other issues suggest that the conclusions are unlikely to be representative of medical device coverage decisions, overall. As Judy said, “It’s almost like they were looking for something that isn’t necessarily there to find.”

To learn more about the study and the concerns Judy and Jo Ellen discussed, read the full story, available to Medical Device Daily subscribers.


Are you concerned about coverage for a medical device your organization is developing? Contact us anytime to schedule a preliminary consultation.

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