By NextBestFitEvidence-based coverage decisions
A public body reviews evidence and stops covering services proven not to work.
Evidence-based coverage decisions.
To review: Controversial; see the rationing subpaths.
Review ledgerHow this path connects
This path
Evidence-based coverage decisions
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Create an evidence-review agency
- Stop covering services proven ineffective
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Low-value care and overtreatment
A public body uses evidence to stop covering services proven not to work, saving money and protecting patients from harmful care.
- Medical errors and poor care coordination
Stopping coverage of services proven not to work protects patients from harmful care.
What it creates or worsens
- Depends on uncertain evidence or judgments
Decisions to stop covering services depend on evidence that is often incomplete.
- Central coverage decisions can feel like rationing
A public body deciding which services to stop covering can generate controversy over coverage decisions.
3 paths soften this
Independent, transparent coverage body with appealsCentral coverage decisions can feel like rationingChosenCover everything clinically effective, without cost thresholdsCentral coverage decisions can feel like rationingRejectedClinician-led exceptions with fast reviewCentral coverage decisions can feel like rationingChosen
Who's affected
Who gains
- People with ongoing or specialist care needs
- Low-value care and overtreatment: Low-benefit tests and treatments expose them to harm.
- Medical errors and poor care coordination: Delivery and coordination failures cause preventable harm.
- Health insurers, brokers, and their shareholders
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Taxpayers and public budgets
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- Central coverage decisions can feel like rationing: Declining low-value care holds down public spending.
Who loses
- Hospitals, clinics, and care organizations
- Low-value care and overtreatment: Per-service payments reward additional low-value care.
- Medical errors and poor care coordination: Fee-for-service providers are paid for treating complications.
- Drug and device makers
- Low-value care and overtreatment: They sell devices and tests used in low-value care.
- Central coverage decisions can feel like rationing: A declined product loses the whole national market.
- People with ongoing or specialist care needs
- Central coverage decisions can feel like rationing: People needing a declined or delayed treatment have no other insurer to turn to.
Where it has been tried
- UK NICE, Germany IQWiG: Health technology assessment.
- Germany: Between 2011 and 2017, IQWiG assessed 216 German-market drug approvals, comprising 152 new molecular entities and 64 new indications, and found no proven added benefit over standard care in 125 assessments (58%).Sources: The BMJ (2019)