Scott & White Health Plan

Medical Coverage Policies

Scott and White Health Plan (Plan) is establishing a process for the development of Medical Coverage Policies which will be available on this website to all plan providers and members.  This process will seek to assure that all Plan members have access to medical advances, while protecting them from services whose effectiveness is unproven.  This process will be intended to allow Plan Medical Directors to maintain a dynamic decision-making process that produces consistent coverage guidance in the face of rapid changes in medical technology and health care delivery. The Plan will develop these policies to cover only services that are reasonable and necessary for the diagnosis and treatment of illness or injury.

In order to as sure the highest quality of care for Plan members, the Plan must control costs while still continuing to assure quality. This cannot be done without authoritative evidence of the value of each individual service. 

Evidence-based decision making will utilize state-of-the-art technology assessment such as that undertaken by Hayes, Inc. and other independent health technology research and consulting companies, and on agencies such as: The Agency for Health Care Policy and Research (AHCPR), The Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Department of Veterans Affairs (DVA), the Department of Defense (DOD), the Center for Medicare and Medicaid Services (CMMS), as well as the advice of the medical community and private sector studies.

Scott and White Health Plan offers coverage for Medicare beneficiaries under a Medicare Cost-Contract (SeniorCare), and Plan Medical Coverage Policies will not supersede Medicare Coverage Determinations for SeniorCare members.  Where there is no Medicare Coverage Determination for a healthcare service, Plan Medical Coverage Policies will be utilized.

Demonstrated effectiveness is the first criterion for determining that a service or health care technology meets the Plan coverage requirements.  There must be authoritative evidence to establish that the benefits of a service or technology to the patient outweigh its reasonably anticipated risks. There must also be authoritative evidence to convince the Plan that use of the service or technology will result in improved health outcomes (such as decreased morbidity or mortality or significantly increased quality of life), for Plan members.  In addition, items or services that are regulated by FDA must have received approval for marketing.

To find authoritative evidence demonstrating the effectiveness of a service on patient outcomes, the Plan will examine:

•  published articles based on controlled clinical trials, other controlled studies, and case series
• formal technology assessments from recognized government and private entities, which examine both published and unpublished data;
• authoritative approvals of other agencies, such as FDA, that a service has therapeutic or diagnostic benefit for patients.

Systems to stratify evidence by quality will be utilized, such as this one by the U.S. Preventive Services Task Force

(USPSTF) for ranking evidence about the effectiveness of treatments or screening:

• Level I: Evidence obtained from at least one properly designed randomized control trial
• Level II-1: Evidence obtained from well-designed controlled trials without randomization.
• Level II-2: Evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one center or research group.
• Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
• Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

 Assessments of health care technology have at least two features that are important to the Plan. First, rather than evaluating services in an investigational setting, they are focused on the effectiveness of technologies in general medical practice and on patient outcomes including morbidity, mortality, health status and health-related quality of life. Second, they use systematic methods for evaluating the quality of the scientific evidence available rather than relying on the less formal examination of medical opinion or consensus. They also grade the quality of the evidence based on the study methods. We have adopted these evidence-based methods as our primary means for making Plan coverage decisions.

Appropriateness

Appropriateness means that a service is suitable for, but not in excess of, the member's medical needs and condition. The qualifications of those providing the service and the setting where the service is provided may be a part of this criterion. The service must be furnished by personnel who are qualified by training, experience and licensure to provide that service and, in some instances, who meet Plan established training levels. The service must be furnished in a setting that is suitable for, but not in excess of, the beneficiary's medical needs and condition and must meet any facility requirements established by the Plan. For example, cardiac catheterization may be covered for some patients in a freestanding facility, but for patients with a high risk of complications, a hospital may be the only appropriate setting for receiving this service.

Comparison with Similar Technologies

It is apparent that cost-effectiveness analysis is extremely controversial for members, providers and suppliers. It raises fears of rationing based on cost. The Plan has not and does not intend to make coverage decisions based solely on cost-effectiveness, and we will not refuse to cover services merely because they are costly. The Plan will review formal cost-effectiveness analyses when submitted for evaluation through the Technology Assessment Process, but the Plan does not require this in order to have a service considered for coverage.

Nevertheless, in order to become prudent purchasers of health care, third party payers, must consider the full value of any medical service they are considering for coverage. Cost-effectiveness analyses, when available, can be used in this regard. These analyses allow the Plan to consider the full range of present and future costs and benefits of a service. Without it, payers and providers often focus on the present costs of expensive technologies rather than on the full value of the service.

Under specific and limited conditions, relative costs and effectiveness will be factors considered in determining Plan payment policy. That is, if a service is more expensive but equally effective, it would still be covered and paid at the rate of the lower cost alternative. If, however, the service is found to be more effective for a specific group of patients, it could be paid at the higher rate. This criterion assures value for the Plan members.

Under some circumstances, coverage may be conditional.  This type of coverage may be used when existing data suggest a potential benefit to some patients, but there is not sufficient information to predict the effect of generalized use of the technology or its long term effects or appropriate patient selection criteria.  Based upon individual review, a service or technology which is not generally covered may receive conditional coverage.