Local Decisions, National Implications & You

It may seem like merely a local skirmish, but an effort by interventional cardiologists in the state of Washington to ensure coverage for drug-eluting stents serves as a roadmap for local and national initiatives targeting other advanced technologies.

We all grapple with the cost of care while trying to do what is best for our patients based on evidence and, in some cases, relying on the art of medicine where evidence doesn’t exist. More than ever before, insurers and others who make coverage decisions are becoming more active and demanding of evidence before considering payment for our services.

As an example, about five years ago the Washington Health Technology Assessment Program evaluated drug-eluting stents with a mandate from the state legislature to determine coverage of state-insured citizens. After an exhaustive and time-consuming process, the committee restricted hospital payment for drug-eluting stents to certain patient groups such as diabetics and vessel sizes and locations such as left main disease. This actually represented a “win” for interventional cardiology because the original determination would have excluded drug-eluting stent use.

This “success” came about through the involvement of a number of physicians, the vendor community and professional societies. Our patients would not have had a voice in this had it not been due to physician involvement.

Stents are not the only technologies being scrutinized by insurers. The Society for Cardiovascular Angiography and Interventions, the American College of Cardiology, the Society of Thoracic Surgeons, the American Association for Thoracic Surgery and other societies were deeply involved in the Centers for Medicare & Medicaid Services (CMS) national coverage determination for transcatheter aortic valve replacement (TAVR) that resulted in coverage for TAVR in Medicare patients. However, at least two private insurance companies either decided not to cover or are considering not covering TAVR for high-risk patients, possibly based on a higher stroke rate and vascular complication rates vs. open surgery in PARTNER I.

This is an odd situation, given that private insurance companies usually follow the lead of CMS. It is also odd because subsequent registry results, PARTNER II and the CoreValve pivotal trial have shown rates of complications that are lower than PARTNER I or are similar to surgical aortic valve replacement. These decisions are being made every day and in every state.

What can you do about this? Get involved locally, and if given the opportunity, nationally. Remember that the groups reviewing coverage decisions are trying to make hard decisions that at first glance may seem ill-informed and not very patient-centric. Your job is to work with them to help inform their decisions.
But remember you will not get everything you believe you should. If you approach the process from the standpoint that it’s “my way or the highway” you will be frustrated and ultimately disappointed.

Also work with the various national societies and use their expertise and resources. This is true even in situations where the decision appears to be local. Many of the groups making these decisions are national, but even state-based initiatives like the Washington Health Technology Assessment Program garner national interest. Other states and insurers use previous decisions and work done by others to guide their strategies.

Don’t fall into the trap of believing that local decisions won’t have national implications. I realize that this type of work is not why you went to medical school. But as patient advocates we must use our deep understanding of the issues to truly inform the process. We must be vigilant, proactive and involved.
Dr. Dean is director of the University of Washington Medicine Regional Heart Center in Seattle.