Technology assessment and coverage decision making.

Abstract

In the health care decision-making cascade, technology assessment renders the initial evaluative judgement about the contribution of a technology to patient care. As such, it has a major impact on coverage policy, clinical guidelines and utilization management. This impact necessitates that technology assessment have a scientific, defensible process. There are four basic components of a scientific, defensible process for both clinical and coverage decision making. These are: 1. Outcomes data that are derived preferably from controlled clinical trials and that support the safety and effectiveness of a specific indication 2. Evidence of acceptance by the practicing medical community of specific applications of a technology 3. A rigorous, evaluative process that synthesizes and analyzes outcomes data and expert opinion 4. Consistency in the use of terminology, as it is translated from the technology assessment process to coverage policy The process must be designed to assure scientific and methodological defensibility. Also, it must be designed to facilitate and substantiate the medical and coverage decision-making processes. Finally, it must be designed to enable and expedite the implementation of the managed care philosophy (i.e., outcomes-based decision making) within a particular health plan.