Improving the Quality and Efficiency of the Medicare Program Through Coverage Policy

A policy paper from the Robert Wood Johnson Foundation describes how Medicare makes decisions about which procedures and technologies to cover, explores particular problems in how Medicare applies policies about covering new services, and outlines opportunities for improvement in the process of making coverage decisions.

According to the paper, Medicare coverage determinations have the potential to act as a policy lever to influence the appropriate use of medical technology and the creation of better evidence to support clinical and health policy decisions. However, constrained agency resources and the lack of high-quality evidence for making informed coverage decisions mean that the vast majority of new technologies and services bypass any meaningful review or are approved without the requisite oversight to assure their appropriate use. The paper offers several achievable steps in five topic areas to improve the coverage process. Some of the changes could be relatively easy to implement, whereas others would require more significant and politically difficult changes, sometimes requiring congressional commitments that do not now exist.