When Effectiveness Isn't Enough: Four Case Studies of Insurance Coverage for Behavioral Interventions Addressing...

Chronic diseases are leading causes of death and contribute over $1 trillion to annual United States health care costs. Behavioral interventions promoting physical activity, dietary changes, and stress management have demonstrated effectiveness in preventing and managing chronic diseases. Despite a strong evidence base, these interventions are not consistently covered by health care payers.

We reviewed publicly available documentation of coverage determinations by CMS and private payers for four behavioral programs: Diabetes Prevention Program, Ornish Lifestyle Medicine, Intensive Behavioral Therapy, and SilverSneakers. We contacted 10 experts with experience in public and private payer decision-making to verify and expand on our insights from these case studies.

Across favorable coverage determinations, we found that robust evidence of effectiveness was not sufficient. Payers also prioritized short-term cost-effectiveness, policy alignment, predicted extent of engagement among policyholders, and scalability of behavioral interventions. Interventions were broadly considered to be preventive care, rather than management of ongoing conditions.

Researchers should document the effectiveness of behavioral interventions for managing existing chronic conditions, not just preventing them. Comparative and economic research findings are key. Behavioral interventions present untapped opportunities for payers to improve health and generate savings, and policymakers and advocates should encourage policies that support behavioral interventions for chronic disease care.