Kaisernetwork.org – Dec. 17, 2008.

As part of its occasional series “The Evidence Gap,” the New York Times on Wednesday examined how Medicare coverage of certain treatments varies by location because CMS leaves “many reimbursement decisions to the discretion of 15 regional contractors around the country.” According to the Times, coverage disparities between states have existed since 1965 when “Congress allowed for regional autonomy in reimbursements” after some physicians and lawmakers “argued that federal meddling in medical decisions would be tantamount to ‘socialized medicine.'”  Click title to read more…

Medicare routinely pays most claims, but “questions frequently arise when it comes to newer treatment and technologies,” the Times reports. To date, “Medicare has resolved only about 300 such questions with blanket national coverage rulings,” while “thousands of other coverage policies have been — and continue to be — decided region by region,” according to the Times. The Times reports that “some experts argue that the regional system is more efficient than having the federal government dictate national coverage in every case.” However, Steven Pearson, president of the Institute for Clinical and Economic Review, said, “Most policymakers think that, in general, we would want to do more national coverage decisions, partly because there’s a concern that the evidence review in most local regions isn’t very good.”

Medicare officials say regional contractors, which generally are units of private insurance companies, “have no financial motive to withhold coverage, because the companies receive the same payment from the government regardless of what treatments are covered,” the Times reports. Steve Phurrough, Medicare’s coverage director in Washington, D.C., said, “Our guidance to them is that if there’s no evidence it works, they shouldn’t pay for it.”

According to the Times, “It remains to be seen” whether President-elect Barack Obama will seek changes to the system. Pearson said, “It would be consistent with your archetype of what a Democratic administration would start to consider as one of its policy options — to someday address the inconsistency.”

The article highlighted the coverage disparities between states for CyberKnife, a “new but fast-growing radiation treatment for prostate cancer” that is covered under Medicare in 33 states (Saul, New York Times, 12/17).