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The waiting game: When will Medicare cover technology?

Physicians say a long and difficult coverage process keeps new technology from Medicare patients for too long.

By Markian Hawryluk, amednews staff. June 2/9, 2003.

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Earlier this year, Leslie Saxon, MD, had to ask a patient to choose between his money and his life. The elderly gardener met all the criteria for people at risk for sudden cardiac death who could benefit from a $30,000 implantable cardioverter defibrillator. The only catch -- he was a Medicare patient.

Although Medicare has approved coverage for the device for other indications, program officials are still weighing whether to cover the device for preventive therapy. Absent Medicare funding, implanting the device could have bankrupted her patient and the grandchildren that relied on him.

Dr. Saxon, a cardiac electrophysiologist at the University of Southern California in Los Angeles, was ultimately able to find an alternative way to pay for the potentially life-saving device, but many other Medicare beneficiaries may not be as lucky.

Many physicians and device manufacturers have pointed to the debate over implantable cardioverter defibrillators as a prime example of how arduous the Medicare national coverage decision process has become.

What has angered Dr. Saxon most is that she thinks clinicians have demonstrated the therapy's benefit. A study in the March 21, 2002, New England Journal of Medicine found that the devices cut the relative risk of death by 31% for patients like the gardener. On the basis of that evidence, the Medicare Coverage Advisory Committee recommended that Medicare expand its coverage. Yet agency officials remain unconvinced.