Insurance Coverage, Physician Recommendations, and Access to Emerging Treatments: Growth Hormone Therapy for Childhood Short Stature

摘要: Context.—There is concern in both the medical community and general public about mechanisms of decision making interplay physician and insurer decisions determining access to care.Objective.—To examine process influencing growth hormone (GH) therapy for childhood short stature by comparing coverage policies of US insurers with treatment recommendations US physicians.Design Participants.—Independent national representative surveys were mailed insurers (private, Blue Cross/Blue Shield, health maintenance organizations, programs for Children Special Health Care Needs, Medicaid programs, n=113), primary care physicians (n=1504), pediatric endocrinologists (n=534) with response rates 75%, 60%, 81%, respectively. Each survey included identical case scenarios. Primary asked about referrals to endocrinologists. Endocrinologists GH recommendations. Insurers therapy.Main Outcome Measures.—Insurer specific case scenarios compared with primary endocrinologists.Results.—Physician insurance differed strikingly. For example, while 96% recommended GH children Turner syndrome, covered GH therapy only 52% these children. Overall, referral decisions by resulted 78% children with deficiency, or renal failure; those recommended for treatment, 28% denied insurers. Similarly, therapy would be recommended 9% idiopathic short stature, but would not cover vast majority these children. Furthermore, data indicated considerable variation among insurers regarding (P<.01).Conclusions.—Access differs depending on type coverage. The deep discord between physician coverage decisions, exemplified findings, represents a major challenge to mechanisms making, access, costs.