Determining Health Insurance Coverage of Technology: Problems and Options

By deciding which medical procedures are eligible for reimbursement, health insurance programs possess the potential to affect significantly technology use and health care spending. Traditionally, insurers have adopted a passive stance and made relatively few negative coverage determinations. However, resistance to rapidly rising costs has created a powerful inducement for third-party payors to become more prudent purchasers of health care services. Consequently, both Medicare and Blue Cross-Blue Shield are considering the implementation of changes that may ultimately result in more restrictive coverage decisions. This article examines the coverage process of Medicare and Blue Cross-Blue Shield and the policy changes that both programs are considering. In addition, it discusses the strengths and drawbacks of four coverage policy options: restricting insurance coverage of unproven procedures, introducing cost-effectiveness criteria, educating physicians and educating consumers.