Who should decide which procedures will be covered by insurance?

Health insurers are expected to pay for medical care, but it can be unclear whether they should be obligated to pay for promising, but unproven, procedures. KFF Health News profiled one patient whose doctor recommended a newer type of treatment. Initially, the insurer refused to cover the treatment, "claiming the treatment was not medically necessary." Soon after media became involved, the insurer changed course. Unfortunately, the patient started different treatment, precluding the recommended procedure.

To some extent, it is in the interest of insurers and those who pay premiums that unproven treatments are not automatically approved. At some point, however, a treatment shows enough promise that it should be considered. Given the advancements in medicine, it is impractical for patients to review an annual list of covered treatment options, and even if they could, there are probably not enough insurance plans for patients to reliably find a suitable option. This scenario raises the question of who should get to decide whether the insurer is obligated to pay for less proven treatments. Currently, the insurer does, but that poses a conflict of interest (similar to giving that power to patients). Theoretically, that decision could be left with physicians, but there is enough variation in the practice of medicine that patients could essentially "shop" for a doctor that would approve an experimental treatment. There could be a role for a panel of physicians to make such decisions for the coverage of experimental treatments.