Want better health coverage? Change your Zip Code

One of the nation’s largest Medicare contractors just decided that it won’t cover a proven new heart monitor that tracks signs of heart failure. That’s terrible news for millions of Americans suffering from cardiac disease.

It’s also a terrifying example of what happens when contractors — and the actuaries who rule their books — take healthcare decisions away from patients and their doctors. Indeed, Medicare’s reliance on private contractors to run the program exacerbates the nation’s health disparities by denying Americans in certain states access to life-saving medical advances. 

{mosads}The Medicare administrative contractor, or MAC, that rejected this monitor is Novitas. In 11 states plus the District of Columbia, Novitas processes and pays Medicare claims. Ultimately, it’s up to MACs — not doctors or even Washington policymakers — to decide if new treatments and technologies will be covered by Medicare in their jurisdictions. 

All too often, the process of local coverage determinations is unpredictable and incoherent — and can leave many Americans without access to vital care. 

The heart monitor decision is illustrative. 

The implantable device, CardioMEMS, recently received approval from the Food and Drug Administration after extensive trials. But Novitas, citing a lack of clinical data, ruled against covering the device. So Americans living within its jurisdiction won’t have access to the monitor, even though it has been shown to lower hospitalization by 48 percent. Among the states impacted are Arkansas, Oklahoma and Mississippi, which have three of the four highest heart failure death rates for women over 65. Most of the states Novitas covers fall among the highest for hospitalizations due to heart failure. 

The Novitas case is not unique. Last year, First Coast Medicare, a MAC which covers Florida, Puerto Rico and the U.S. Virgin Islands, also declined to cover CardioMEMS. The device would be particularly useful in Florida, with its large senior population. Three out of 10 deaths in Florida are due to cardiovascular disease. 

Other devices are at risk, too. Last fall, CGS Administrators, a MAC which covers medical equipment in 38 states, put forward a plan to deny access to certain prosthetics. If this proposal moves forward, other contractors and even private insurers could follow suit, negatively impacting 2 million amputees.

Indeed, the consequences of negative local coverage decisions can easily extend beyond a contractor’s jurisdiction. For example, Novitas currently is considering denying coverage for ChemoFx, a lab test that determines which drugs will most effectively treat ovarian cancer. ChemoFx is based in Pittsburgh, which is under Novitas’ jurisdiction. But doctors across the country send samples off to Pittsburgh to be tested. So if Novitas makes an unfavorable decision, then the Pittsburgh plant could close down — impacting doctors and patients around the country who rely on its lab results. 

In many cases, access to these devices and treatments could save and lengthen lives and curb healthcare spending. But current procedures for coverage decisions have created a healthcare landscape where certain services and treatments are available and covered by Medicare in one state but unavailable in the next. 

A recent report by the Inspector General of the U.S. Department of Health and Human Services confirmed this discrepancy and raised concerns. The report examined coverage decisions for services under Medicare Part B, the part of the program that covers outpatient care. The report found that of the 7,500 submitted procedure codes, the methodology used to identify medical procedures, half were subject to the decisions of local contractors. 

The problem of unequal access has been a recurring one for Medicare. A 2003 Government Accounting Office report found similar discrepancies in MAC coverage for new medical technologies. Lawmakers passed a national coverage law to remedy the problem, but problems continue to the detriment of patients based on where they live. Seniors deserve access to treatments based on their health needs, not their zip codes.

There’s a particular irony in the case of CardioMEMS. This is a device that keeps people out of the hospital — an important nationwide goal established by the Medicare program. Medicare now penalizes hospitals with excessively high readmission rates, by docking reimbursement rates for Medicare services by as much as 3 percent. 

More than half of the hospitals in nine states within the Novitas network have been penalized for excessive readmissions. Meanwhile, heart failure patients managed using CardioMEMS had almost half the rate of hospitalizations compared with patients managed using the standard of care two and half years after receiving the device – and counting. Covering CardioMEMS could help lower readmission rates, bringing significant savings to the nation’s healthcare system and preventing hospital stays for people living with heart failure. 

Advances in medical technology are lengthening lives and beating previously untreatable diseases. Americans suffering from heart disease, or any other treatable ailment, should not be denied a chance to benefit from these advances based on where they live. 

Kenneth E. Thorpe is professor of health policy at Emory University and chairman of the Partnership to Fight Chronic Disease.