Medicare Lacks Tools to Enforce Coverage Policies

New School of Public Health research finds that Medicare lacks the tools and incentives necessary to enforce its evidence-based coverage policies.

And Medicare appears reluctant to aggressively enforce policies that affect medical judgments, even if those decisions are inconsistent with scientific evidence.

"There has been much discussion among providers, payers, and policymakers to encourage evidence-based medicine as a means to improve quality and reduce costs," says SPH professor Susan Bartlett Foote, who led the study. "We've found that there are considerable barriers to achieving that goal in Medicare."

By law, Medicare must pay only for items or services deemed "reasonable and necessary." The program has developed evidence-based coverage policies to evaluate which medical procedures will be covered and under what clinical circumstances.

Medicare contractors who process claims for payment are directed to apply these policies to determine when to pay or deny a claim. While policymakers may assume that Medicare's coverage policies change physician behavior, Foote's research shows that they don't. She says improving information and education, aligning incentives, and investing in compliance are ways to improve the coverage policies.

When Medicare was passed in 1965, professionals were assured that the program would not interfere with the practice of medicine. But Medicare is also directed not to pay for procedures unless they are "reasonable and necessary."

Foote says there's an inherent tension between these goals.

"Public and private payers are often reluctant to secondguess doctors and other professionals," says Foote. "However, in an era of rising costs and questionable quality, we must refine tools to ensure that patients get care based on scientific evidence."