National Health Policy
Conference, 2005:
Analysis of Differences in Local
Coverage Policies
Susan Bartlett Foote, J.D., M.A.
Division of Health Services Research and Policy
University of Minnesota
February 2, 2005
1
MMA: “Secretary is also required to develop a plan to
evaluate new local coverage determinations to decide
which local decisions should be adopted nationally and to
decide to what extent greater consistency can be achieved
among local coverage decisions, to require Medicare
contractors within an area to consult in new local coverage
policies, and to disseminate information on local coverage
decisions among Medicare contractors to reduce
duplication of effort ... on or after July 1, 2004.”
MMA Sec. 731, amending Sec. 1862 of SSA.
2
1
Citations
“Focus on Locus: Evolution of Medicare’s
Local Coverage Policy,” Health Affairs,
July/August 2003.
“Resolving the Tug-of-War Between Medicare’s
National and Local Coverage,” Health Affairs,
July/August 2004
„ “Variation in Medicare’s Local Coverage
Policies: Content Analysis of LMRPs,”
forthcoming, American Journal of Managed
Care.
„
3
Research Methods
Survey of CMPs – FIs and Carriers (n=67)
48 organizations administering 1 or
more contracts
60% response rate
(57% FIs, 62% carriers)
4
2
LMRP Database
Final data set – 6,900 policies
(5,213 carrier/1,687 FI)
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Classification of Policies
UM – utilization management
NT – new technology
TE – technology extension
MD1
MD2
73.1% - 88.6%
16.1% - 8.4%
10.8% - 3%
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3
Case Studies – Methods
„
„
„
„
„
Carrier policies
Agreement on classification
>20 posted policies
2 selected from each of 3 policy types –
UM/NT/TE
1 treatment/1 diagnostic
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Case Studies
NT - Deep brain stimulation
H.pylori breath test
UM - Toenail debridement
CV stress test
TE - Urethral stents
Transesophageal echocardiography
8
4
Findings
„
How did local contractors get authority
to make coverage policy?
„
„
Accident of history
What does the local contractor
environment look like?
„
Consolidation into networks
9
From: Foote, S.B., (2003). Focus on Locus: Evolution of Medicare’s Local Coverage Policy. Health Affairs
22(4):137-146.
5
Fiscal Intermediaries with One State Contract, 2002
MT
RI
WY
PA
NE
KS
OK
AZ
AR
GA
FL
Individual Blues
FI Contracts (11)
SOURCE: Map developed from data on the CMS-sponsored website, “Local Medical Review Policies,” 2002, <www.lmrp.net/download.asp> (21 January 2003).
Fiscal Intermediary Networks with Multiple Contracts: Adminastar and United Government Services, 2002
VT
ME
NH
MA
WI
MI
NV
IL
CA
IN
OH
WV
KY
HI
VA
Adminastar Federal, Inc.
FI Contracts (8)
United Government Services
FI Contracts (7)
SOURCE: Map developed from data on the CMS-sponsored website, “Local Medical Review Policies,” 2002, <www.lmrp.net/download.asp> (21 January 2003).
6
Carrier Network with Multiple Contracts: Noridian Mutual Life, 2002
WA
ND
OR
SD
WY
IA
NE
CO
AR
AK
HA
Noridian Mutual Life Insurance Company
Carrier Contracts
(11)
SOURCE: Map developed from data on the CMS-sponsored website, “Local Medical Review Policies,” 2002, <www.lmrp.net/download.asp> (21 January 2003).
Carrier Network with Multiple Contracts: National Heritage Insurance Co., 2002
ME
VT
NH
MA
CA
National Heritage Insurance Company
Carrier Contracts (5)
SOURCE: Map developed from data on the CMS-sponsored website, “Local Medical Review Policies,” 2002, <www.lmrp.net/download.asp> (21 January 2003).
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Variation in Resources
„
Size as measured in volume of claims
processed
„
„
„
2.1 million – 82.6 million claims
Perception of resources varies
Number of FTE available for LMRPs
„
.05 FTE – 9 FTE
15
Overcome Resource Restraints
„
„
„
73% always review LMRPs of others
CACs if available
Larger ones can purchase commercial
TA
16
8
Variation in Productivity
„
„
Extensive variation in number of
procedures subject to policy
limitations or specifications
Use of scientific journals
„
„
72% reported always rely on scientific
journals
46%-48% cited at least one journal
article for NT
17
From: Foote, S.B., (2004). Resolving the Tug-of-War Between Medicare’s National and Local Coverage.
Health Affairs 23(4):108-123.
18
9
Timeliness
19
Diffusion of Local Medical Review Policies
SOURCE: LMRP website, www.lmrp.net/dowload.asp, 31 May 2001 and 2 April 2002
From: Foote, S.B., (2004). Resolving the Tug-of-War Between Medicare’s National and Local Coverage.
Health Affairs 23(4):108-123.
20
10
Diffusion of Local Medical Review Policies
(continued)
SOURCE: LMRP website, www.lmrp.net/dowload.asp, 31 May 2001 and 2 April 2002
From: Foote, S.B., (2004). Resolving the Tug-of-War Between Medicare’s National and Local Coverage.
Health Affairs 23(4):108-123.
21
Identification of Leaders
Contractor size and NT leadership
correlated (1 of first 3 to write a policy)
Top 5 FIs = largest claims volume
„ Top 3/5 carriers = largest claims volume
„
22
11
Findings from the Case Studies
Foote, Susan B., Rachel Halpern, & Douglas Wholey.
(forthcoming, Spring 2005). “Variation in Medicare’s
Local Coverage Policies: Content Analysis of LMRPs,”
American Journal of Managed Care.
23
Concentration in Diagnosis Codes, NT Policies
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Concentration in Diagnosis Codes, TE Policies
25
Concentration in Diagnosis Codes, TE
Policies (continued)
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13
Concentration in Diagnosis Codes, UM
Policies
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Concentration in Diagnosis Codes, UM
Policies (continued)
28
14
Concentration Measures for Procedure
Codes
Number of HCPCS
Category
Case
NT
DBS
20
66.04
H. pylori
18
64.26
TEE
9
84.32
Urethral
6
97.96
Stress
69
38.81
Toenail
15
64.65
TE
UM
Codes Cited
% in Top Five
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Conclusions
NT & TE
„ Not widely different in content
„ Timing differences
„ Little evidence for TA depth
„ Multiple processes for similar conclusions
„
„
„
Issues of quality of TA
Issues of equity/access for beneficiaries
Issues of efficiency
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15
Conclusions (continued)
UM
„ Lots of variation
„ Since widely diffused, issues of access?
„ Assessments based on guidelines and
clinical evidence
„ Variation may mean quality of care issues
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Ongoing Studies
„
„
„
Link between policies and claims?
Do policies matter?
Link between PPOs and contractors.
32
16
MA Regions
Source: www.cms.gov
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Conclusions
„
„
„
„
„
promote EBM in Medicare
promote accountability in Medicare
promote consistency in coverage
where appropriate
improve Medicare processes
avoid geographic incoherence
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