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Evidence-based health care coverage for children: proceed with caution
1George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy, Washington, DC 20006, USA. ewehr@gwu.edu
Insights
Evidence-based healthcare coverage is challenging for children due to limited pediatric research. Policymakers must recognize the limitations of cost-effectiveness data when making coverage decisions for pediatric care.
Area of Science:
- Health Services Research
- Pediatric Health Policy
- Evidence-Based Medicine
Background:
- Managed care organizations increasingly link healthcare coverage to research data and cost-effectiveness analyses.
- Children face unique research challenges, resulting in a scarcity of pediatric-specific data.
- Current federal initiatives to boost pediatric research are unlikely to yield immediate results.
Purpose of the Study:
- To highlight the difficulties in applying evidence-based coverage standards to pediatric healthcare.
- To examine the implications of insufficient pediatric research for healthcare access.
- To inform purchasers and policymakers about the limitations of current evidence-based coverage models.
Main Methods:
- Analysis of existing literature on pediatric research challenges.
- Review of managed care contract trends regarding evidence requirements.
- Examination of cost-effectiveness analysis methodologies and their limitations.
Main Results:
- Limited pediatric research data makes it difficult to meet evidence-based coverage standards.
- Absence of data can lead to coverage denials based on negative assumptions.
- Population-based evidence is often inadequate for individual patient coverage decisions.
- Cost-effectiveness analyses lack standardization and may be subject to bias.
Conclusions:
- Purchasers and policymakers must understand the limitations of evidence-based coverage standards for pediatric populations.
- Over-reliance on incomplete evidence can negatively impact children's access to necessary healthcare.
- Alternative uses of evidence may be more effective for systemic healthcare improvements.
Abstract:
Making health care coverage depend on the existence of valid, applicable research data and positive cost-effectiveness analyses, as managed care contracts are beginning to do, is particularly problematic for children. Because of research challenges specific to children, there are relatively few pediatric data and analyses required under such evidence-based coverage standards. It is too soon to expect major increases from federal efforts to stimulate pediatric health care research. But absence of requisite evidence would entitle a managed care organization or other decision maker to deny coverage on the basis of unproven, negative assumptions about an intervention. In general, population-based evidence is an incomplete basis for decisions on coverage for individual patients. Cost-effectiveness analyses are not standardized and may be biased. Purchasers of managed care and policy makers should understand the limits of evidence-based coverage standards. Other uses of evidence may contribute more to systemic improvements of health care.