Evaluating medical effectiveness for the california health benefits review program

Abstract

An important aspect of the mandate assessments requested by the California legislature is a review of the scientific and medical literature on the medical effectiveness of the proposed health insurance benefit mandate. Although such a review bears many similarities to effectiveness reviews that might be undertaken for publication as research studies, several important differences arise from the requirements of the California legislation. Our reviews are intended to assist the legislators in deciding whether to support a specific mandate to modify health insurance benefits in a particular way. Thus, our assessments focus on how the scientific literature bears on the proposed mandate, which may involve a complicated chain of potential effects leading from altered coverage to ultimate impact on health. Evidence may be available for only some of the links in the chain. Furthermore, not all the evidence may be directly applicable to the diverse population of California or the subpopulation affected by the mandate. The mandate reviews, including the medical effectiveness analyses, may be used in a potentially contentious decision making setting. The legislative calendar requires that they need to be timely, yet they must be as valid, credible, and based on the best information available as possible. The focus on applicability also implies the need for informed, technical decisions concerning the relevance of the articles for the report, and these decisions need to be made as transparent as possible. These goals and constraints yield an approach that differs somewhat from an investigator-initiated review of the literature.

Figure 1

Schematic of a Mandate for Covering a Test

Figure 2

Steps in a California Health Benefits Review Program (CHBRP) Medical Effectiveness Analysis