By NextBestFitClinician-led exceptions with fast review
Clinicians can request coverage for individual patients outside the standard list, decided within days by a clinical panel.
Fast exceptions for unusual cases.
Review ledgerHow this path connects
This path
Clinician-led exceptions with fast review
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Create a fast clinician exception process
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
- Central coverage decisions can feel like rationing
Allowing clinicians to request prompt clinical-panel decisions outside the standard coverage list gives unusual cases flexibility through a clinician-driven process.
What it creates or worsens
- Racial, income, and geographic disparities
Individual exceptions to the standard coverage list raise concerns about equity in coverage decisions.
Who's affected
Who gains
- 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.
- Drug and device makers
- Central coverage decisions can feel like rationing: A declined product loses the whole national market.
- Hospitals, clinics, and care organizations
- Racial, income, and geographic disparities: They can select better-paying patients over those with lower-paying coverage.
Who loses
- Taxpayers and public budgets
- Central coverage decisions can feel like rationing: Declining low-value care holds down public spending.
- Black, Hispanic, and Native communities
- Racial, income, and geographic disparities: Access and outcomes differ by race, income, and location.
- Rural residents
- Racial, income, and geographic disparities: Access and outcomes differ by race, income, and location.
- Low- and middle-income households
- Racial, income, and geographic disparities: Access and outcomes differ by race, income, and location.
Where it has been tried
- NHS England Individual Funding Requests: Case-by-case exceptions.
- United Kingdom (England): A study first published in 2020 found IFR decline rates of 71% for NHS England and 34% for CCGs, with lack of exceptionality cited for 42 of 45 declined requests submitted in 2016–2018.