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Carrier Advisory Committee Network Meeting 2005 Focuses on Key Issues in Medicare Coverage

The primary reason for variations in Medicare coverage is that 90% of coverage decisions are made at the local level, said James Rollins, MD, MSHA, PhD, of the Centers for Medicare & Medicaid Services (CMS), who discussed regulatory issues at the meeting. He noted that regional variations in community care standards lead to different decisions in different areas of the United States. Carrier medical directors at contracted insurance companies follow an evidence-based medicine approach to make local coverage determinations, taking into consideration relevant medical literature as well as comments from the local CAC, medical societies, and medical consultants.

National coverage determinations would create more consistency across the country, but some vendors do not seek a national-level decision. "Once a CMS decision is made, it trumps all local decisions; some vendors may not want to take that risk," said Rollins. Many CAC representatives noted that the time needed for the CMS decision process is a problem. At least 6 to 9 months, and often longer, is needed for the evaluation process, and this timeframe does not keep pace with some of the rapid advances being made in cancer treatment. They added that it is unethical not to treat a patient with new therapy that has been shown to be effective; yet the lack of Medicare coverage means that treatment is not a viable option for many patients. Meeting attendees sought answers for ways to work with CMS to make this process more rapid.

One solution to the problem may be to effect change at the local level, by enhancing the relationship between CAC representatives and carrier medical directors (CMDs). In a keynote address prior to the meeting, Alton Wagnon, MD, CMD for Utah, presented a variety of ways to "bridge the gap" between CMDs and CAC representatives. At the meeting, Wagnon joined former CMDs Arnold Krubsack, MD, and Grant Steffen, MD, on a panel that fielded questions from attendees on how to gain support for coverage decisions. The panel noted that CAC representatives can be a reliable resource for a CMD and it encouraged representatives to introduce themselves to their CMD, to invite them to their state society meeting, and to be proactive by setting up regular face-to-face meetings with their CMD and offering to help. The panel also pointed out that it is important to obtain evidence-based medicine to support a position before contacting the CMD and to network with other CAC representatives to present a unified front, especially when dealing with a multistate carrier.

The panel members also reminded attendees that CMDs must abide by CMS statutes, one of the most important ones being 1862 (a)(1)(A) of the Social Security Act, which states that "no payment may be made...for any expenses incurred for items or services...not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the functioning of a malformed body member." Wagnon explained that one problem with the "reasonable and necessary" statute is differing definitions. "Clinicians start with the disease and determine what treatment fits," he explained, "and CMDs tend to begin with the treatment and see if it is appropriate for a disease.

The CAC process is integral to developing reimbursement policies that allow for delivery of the highest quality care, and practicing oncologists can also help to ensure that appropriate drugs and procedures are covered by becoming more involved at the local level. The ASCO Web site (http://www.asco.org) offers easy access to the Medicare Coverage Database (MCD) on the CMS Web site (http://www.cms.hhs.gov/); the MCD is a comprehensive online repository for all local medical review policies and local coverage determinations from Medicare carriers. ASCO's site also includes links to subscribe to carrier e-mail lists that will keep oncologists up to date on local coverage policies. Understanding the existing policies will help oncologists be fully informed before they present their situation to their CAC representative. A complete list of CAC representatives and CMDs, arranged by state, is also available at http://www.asco.org/cac, as well as contact information for state societies. Because state/regional societies are engaged in the CAC process, they can provide guidance about local coverage as well as facilitate discussions with the CAC representative.

Ways Practicing Oncologists Can Become More Involved With Coverage Issues Top Ways Practicing Oncologists Can...   Know your CAC representative. Work with your state society on CAC issues. Sign up for your carrier's e-mail discussion list. Remain up to date on local medical review policies or local coverage determinations. Notify ASCO about coverage policies that you believe are inappropriate.

 

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