New application of existing technology coverage determination
New technologies and new applications of existing technologies are evaluated and approved for coverage when they provide a demonstrable benefit for a particular illness or disease; are scientifically proven to be safe and efficacious; and there is no equally effective or less costly alternative.
Emerging and innovative technologies are monitored by Providence Health Plan through review of trend reports from technology assessment bodies, government publications, medical journals and information provided by providers and professional societies.
A systematic process for evaluating a new technology or new application of an existing technology is proactively initiated when sufficient scientific information is available.
Plan-developed standards guide the evaluation process to assure appropriate coverage determinations. New technology must minimally meet the following guidelines to be approved for coverage:
- Technology must improve health outcomes. The beneficial effects must outweigh any harmful effects on health outcomes. It must improve the length or quality of life or ability to function.
- Technology must be as beneficial as any established alternative. It should improve the net health outcome as much, or more than, established alternatives.
- Application of technology must be appropriate, in keeping with good medical standards and useful outside of investigational settings.
- Technology must meet government approval to market by appropriate regulatory agency as applicable.
- Criteria must be supported with information provided by well-conducted investigations published in peer-reviewed journals. The scientific evidence must document conclusions that are based on established medical facts.
- Opinions and evaluations of professional organizations, panels or technology assessment bodies are evaluated based on the scientific quality of the supporting evidence.
Technology evaluation process
A core committee of Providence Health Plan medical directors and high-level physician specialists, practitioners and/or pharmacists evaluate and recommend coverage for new technologies. Their decisions are based on information provided by professional assessment and policy development organizations, as well as other medical experts.