Reference no: EM133512164

Question

1. What type of information should Dr. Beekley and her colleagues collect about the new test when assessing whether to cover it?

2. Who might she consult when reviewing whether the test has value?

3. What is more important, the efficacy or the cost of the test? Why?

4. Should health insurance plans be able to decide what products and services are covered

Dr. Janice Beekley is the medical director of one of the largest health insurance companies in America. It is her job to review new medical technologies and determine which ones will be covered by the health plan and which will not. To decide this, she and the committee of experts she works with review new products to see whether they have significant clinical value and what the cost of covering them would be. When products are not as effective as the current standard of care, they are usually not covered. When they are as effective but more expensive, they may also not be covered. When products are more effective but very costly, the insurance plan usually reimburses for their use-but may create access barriers to them so that physicians and patients have to demonstrate they absolutely need something prior to having access to the service. Examples of this include CT scans for assessing back injuries. Dr. Beekley and her colleagues recently reviewed all the published evidence about CT scans to assess back injuries and came to the conclusion that they were being overused. Additionally, CT scans are very expensive and were costing health insurers millions of dollars every year. Dr. Beekley created a specific policy that outlined when CT scans can and cannot be used. If patients get a CT scan for one of the unapproved reasons, they will have to pay for that imaging test out of their own pocket. This could cost them close to $1,000. As a result, another initiative Dr. Beekley is working on is helping people to understand what is covered and what is not and how to look up that information as part of the routine health care process. Dr. Beekley's task for today is to evaluate whether the health insurance company should cover and pay for a new test for cervical.