Little is known about how payers of care, both public and private, determine which medical technologies they will reimburse for in their benefit packages. The purpose of this study if to a) determine how private and public payers of health care decide whether or not to include new innovative technologies in their benefit packages, using genetic tests as a prototype, and b) identify the elements of federal and state health care reform policies which may influence the diffusion of genetic tests into clinical practice. Evaluations of new technologies should include scientific considerations of: the effectiveness of the tests, b) costs and benefits of providing the tests, c) the supply of qualified providers to administer the test and d) the demand for the test by consumers. Although some companies or public agencies may consider these criteria in deciding what tests to cover, the weights applied to each criterion are unclear. Evidence suggests that the weights may differ across tests/services and between companies. The study will be done in two phases. In phase I, legislators active in health care reform and private insurers in the Mid-Atlantic region will be interviewed. Preliminary information regarding proposals for state reform and company policies on reviewing new technologies will be collected and used to design the questionnaire for the final survey. The questionnaire will be pilot tested in telephone interviews with the director of benefits in 15 different insurance organizations in the Baltimore-Washington area. The final survey will consist of 60 telephone interviews with a key person involved in setting benefits in each of the major categories of payers (N= 10 HMOs, 10 PPOs, 10 managed indemnity, 10 traditional indemnity, 10 self-insured companies and 10 state Medicaid offices) in ten geographical regions of the United States. Analysis of the data will be largely descriptive. The sample is not being selected to give a representative picture of how each type of insurer in each region is likely to determine benefits. Instead, the aim is to expose the range of factors that payers consider in determining reimbursement policies, and begin to see how these differ depending on the type of insurance, the type of payer (e.g. employer vs private vs public insurance), the type of test, the payment arrangements (prepaid vs fee-for-service) and in response to federal and state reform initiatives. Identification of the potential barriers to objective technology review may help to minimize subjective or arbitrary determinations and promote more equitable access to new technologies for consumers that exists under the current health system.
