National Institutes of Health Clinical Center


Health Policy

Applying Evidence to Insurance Design, Coverage, and Reimbursement Policies

Summary: This line of research and policy development seeks to address the ethical challenges that arise from using evidence-based medicine to guide insurance benefit design, coverage, and reimbursement policies. The process of generating and applying evidence on clinical and sometimes cost-effectiveness within insurance systems has long been a controversial flashpoint where the goals of access, innovation, and cost containment often conflict. Recently, in the United States, the questions regarding the use of scientific evidence in medical policies gained new notoriety during the controversies over changed recommendations for mammographic screening and over provisions of the health care reform legislation that creates a new federal initiative in comparative effectiveness research.

Specific questions addressed by this line of research include: how to balance consideration of possible risks and benefits of new technologies; how to manage uncertainty about the effectiveness of new technologies when deciding whether provide insurance coverage ; how to align benefit designs and reimbursement policies with assessment of the value of new technologies when perceptions of "value" differ between patients, clinicians, and payers; and how to consider the ethical ramifications of the dominant utility-maximizing perspective of cost-effectiveness analysis. The overall objective of this line of research is to provide empirical and normative analyses of approaches to balancing access, innovation, and cost control in support of an equitable and sustainable health care system.

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