Medicare’s coverage decisions need more input from physicians

It is no secret there is a constant tension between physicians who want to be able to make the decisions they feel are in the best interest of patient care and the payers who, physicians believe, often unnecessarily insert themselves in the physician-patient relationship. Nowhere has this intrusion become more noticed and more erratic than in the process of drafting Medicare local coverage determinations (LCDs).

Every day, I and my colleagues in the pathology profession see the best interests of patients being adversely affected by faulty decisions in Medicare’s local coverage program, a government process that lacks transparency and accountability and, at times, interferes with the physician’s medical judgement.

{mosads}Medicare LCDs are written by Medicare Administrative Contractors (MACs), which are private entities contracted by Medicare to process claims, make reimbursement decisions on a range of items and services including medical procedures, office visits, imaging, drugs, and laboratory tests. There are 12 MACs for Medicare’s hospital- and office-based services, providing Medicare coverage, claims processing, and enrollment services for physicians across the country.

In pathology, as well as all of medicine, misguided LCDs developed by these MACs can often prevent patients from receiving the right test at the right time.

For these reasons, it has never been clearer that the Medicare LCD process is in need of reform. That is why more than 75 state and national physician organizations, patient advocacy groups and national cancer organizations support the passage of the Local Coverage Determination Clarification Act to reform the LCD program. S. 794, introduced by Sens. Johnny Isakson (R-Ga.), Tom Carper (D-Del.), Debbie Stabenow (D-Mich.), and John Boozman (R-Ariz.), deserves the attention of, and support from, all provider and patient advocacy organizations.

The reasons reform is needed are obvious to any health care provider: the current process lacks accountability and transparency. Physicians are finding more examples of local Medicare coverage decisions being drafted in a way that’s not in the best interest of their patients.  

While these are reasons enough to reform the LCD process, it does not fully encompass the many concerns the College of American Pathologists (CAP) and the other supporters of reform have with LCDs. These include trends by some MACs to use selective and dubious evidence to set practice standards or determine utilization thresholds. In addition, many organizations feel LCD evidentiary standards are highly selective, misrepresent the opinions of national organizations, and contain several key premises that are unsubstantiated.

Another strong concern about the current LCD process is the erosion of the role of Contractor Advisory Committee (CAC) representatives, specialists in their field, whose role is to advise MACs on LCDs. In several meaningful cases, very limited dialogue between the CACs and MAC occurred during the policy development process. Finally, there’s a lack of a meaningful appeals processes for providers/supplies when a MAC either denies a reconsideration request or declines to make changes to an LCD.

Reform of the LCD process is critical and the proposed legislation will ensure that Medicare determinations do not override physician medical judgment and deny patients access to medically necessary care. The CAP believes current LCDs might adversely affect care decisions by causing pathologists to delay diagnosis, choose testing methods that lead to higher rates of misdiagnosis, or subject patients to unnecessary intervention that are potentially harmful.

Providers have joined together to support S. 794 to ensure coverage decisions are made by qualified, independent health experts through a transparent process based on sound medical evidence. Only in this way can we assure patients that physicians are able to provide care consistent with the best clinical evidence, not the decisions of a third-party insurance administrator.

Richard C. Friedberg, MD, PhD, FCAP, is president of the College of American Pathologists (CAP).

The views expressed by this author are their own and are not the views of The Hill.