Technology Coverage Decisions by Health Care Plans and Considerations by Medical Directors

OBJECTIVES: Decisions made by private health care plans as to whether to cover new medical technology have a significant impact on access, diffusion, and costs. This study describes the variation in health plan coverage of different laser technologies and the types of considerations used in making coverage decisions for them. METHODS: In a cross-sectional national survey of medical directors at private plans, medical directors indicated current coverage of 15 different laser therapies, and then ranked the top five considerations both in favor and against recommending coverage for three of the laser therapies (angioplasty, discectomy, and photodynamic therapy). The influence of explicit clinical information and/or plan characteristics on coverage and the importance of considerations was examined through multivariate analyses (multiple logistic or linear regression analysis). RESULTS: Overall, 231 medical directors responded from plans representing 66% and 72% of persons in US health maintenance organization and indemnity plans, respectively. Current coverage for 13 of the 15 laser therapies varied between 20% and 90%. For-profit and indemnity plans covered approximately two more of the different laser technologies than nonprofit plans and health maintenance organizations. Considerations most frequently listed in favor of and against recommending coverage across the three laser technologies were clinical, economic, and regulatory. Legal, competitive, and compassionate concerns were listed less frequently. Considerations were not uniform across laser therapies; they reflected the specifics of the technology under review. Plan characteristics influenced the ranking of considerations as well. For instance, health maintenance organizations were two to three times more likely than indemnity plans to list potential for decreased cost in favor of recommending coverage. CONCLUSIONS: These findings demonstrate that there is substantial variation in coverage of new technologies, indicating that a large proportion of the population covered by private health plans are ineligible for treatments that are routinely available to others. A greater range of medical therapy may be available for persons enrolled in indemnity and for-profit plans should their physicians choose to prescribe it. Clinical and economic considerations, including cost-effectiveness, predominate in coverage decisions for new technologies. The importance of considerations appears sensitive not only to specific clinical information, however, but also to characteristics of health plans.