Intended for healthcare professionals

Observations Yankee Doodling

Linking health insurance coverage to evidence

BMJ 2013; 347 doi: (Published 05 July 2013) Cite this as: BMJ 2013;347:f4270
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}

Be careful what you wish for

Everyone agrees that we want healthcare policies of all sorts to be informed—if not governed—by the best evidence available. This applies to coverage and payment for drugs and services, whether for prevention, diagnosis, or treatment. It may be especially important for preventive services, for two reasons.

Firstly, to put it baldly, preventive care is optional. If a patient has a broken ankle or a weeping ulcer, we have to do something, whether there are randomized trials supporting the choice of treatment or not. Not so for a screening test. Before we take an asymptomatic patient and recommend mammography, say, or a cervical smear test, we want strong evidence that the benefits (better outcomes, preferably) have been proved to outweigh the harms (side effects of the test and subsequent treatment).

Secondly, there is already a lot of good quality evidence about preventive care. Many of the major screening tests, immunizations, and some counseling interventions have been examined in high quality studies. We often know the effectiveness of specific preventive services: what should be done and, on occasion, what shouldn’t.

None …

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