Washington State’s Health Technology Assessment (HTA) program has attracted some strong criticism. It’s easy to see why. The program determines health insurance coverage for about 750,000 people, including state employees and Medicaid recipients, by assessing the efficacy and cost-effectiveness of various procedures. Critics deride the “inquisition” and “the spectacle of doctors forced to justify their practices, if not yet their existence, to a government board” where “evidence and rationality will have to compete with the … political imperative to control costs.”

Remarkably, though, this state program has not been a political lightning rod at home – criticism comes mainly from outsiders. Why the difference? Ample explanations are provided by the origin of the program, its context, and its operation. 

From its beginning the HTA had bipartisan support. In 2002, Washington began collaborating with Oregon, which was already operating a program to review prescription drugs for comparative effectiveness, to determine state-funded coverage. The program caught the eye of a number of Washington state legislators, both Democrats and Republicans, who asked, why should the state pay for more expensive but only equally effective drugs, or pay as much for less effective ones? Washington contracted with the Center for Evidence-Based Policy of the Oregon Health Sciences University to use its review findings.

Washington legislators quickly became aware of the dramatic savings for the state’s Public Employee Benefits program and the Uniform Medical Plan, which serves many public sector retirees. These plans began to see little cost growth during 2004 — 2005, a time when private plan costs were routinely rising 5% to 8%. 

Once the cost-saving results of drug review became apparent, legislators got interested in expanding the review into medical treatments more generally. This they did in 2006, creating the HTA program. In expectation of greater resistance from physicians and device suppliers, the legislation wisely stipulated that the membership of the key clinical evidence review committee would be entirely practicing health care professionals.

HTA’s careful and open process also helps explain why the program has attracted relatively little in-state political controversy. All meetings are public, and the review committee posts online both its reasoning and the full evidence reports on which its reasoning is based. Decisions to undertake a review of a specific device or procedure are made either when sufficient studies have emerged to cast doubt on its comparative efficacy or when a treatment that is emerging into high-volume use seems to be based on little if any positive evidence. The primary criteria used in coverage reviews are safety, efficacy, and the direct impact on state costs. Secondary criteria include severity of condition treated, impact on special populations, and other ethical concerns.

The committee has made 21 coverage decisions so far. Eleven were largely negative, including virtual colonoscopy, arthroscopic surgery for arthritic knees, implantable drug infusion pumps, and spinal cord stimulators. Ten were mostly positive, including lumbar fusion for uncomplicated disk degeneration, artificial lumbar and cervical disks, and coronary CT angiography. Negative decisions are seldom completely negative, often allowing treatment as appropriate for a narrow range of conditions.

The savings so far have not been huge – annually, less than 1% of the roughly $3 billion in state health care spending. As the number of such decisions expands, however, total annual savings will undoubtedly grow. 

Some reviews have met considerable resistance from medical specialists, device manufacturers, and patient lobbies. The 2008 review of implantable drug-infusion pumps for non-cancer-related pain and the resulting decision not to cover these devices because of unproven effectiveness and safety sparked great controversy. Professional resistance among health care providers, however, has not been massive, and it has seldom translated into larger political or partisan battles about whether to have a review process for state spending at all. 

The larger medical-historical context of the state also helps explain the HTAs wide support. It was in Washington that one of the first member-owned health maintenance organizations, Group Health Cooperative of Puget Sound, arose in 1947. GHC was often accused of rationing care to make its bottom line, but it had its defenses. It was nonprofit and member-owned, and, therefore, its managed care could not be so easily viewed as gouging the patient. And research began to show that its outcomes were at least as good as, if not better than, competing providers’ outcomes. 

National reform has highlighted a connection between coverage and payment. If insurance is mandatory, those required to buy it can ask all the more rhetorically why they should have to pay for services backed by little evidence of comparative effectiveness. Taxpayers, who will subsidize insurance mandates for those who struggle with affordability, can easily get indignant at the thought of supporting comparatively ineffective care. 

Going forward, part of the continued political viability of HTA will undoubtedly also depend on its review committee using cost–effectiveness data in only moderate ways. That is already its practice. Decisions are a function of the quality of evidence for comparative effectiveness, the degree of the effectiveness for which there is evidence, and the relative cost. This does not constitute putting any primary emphasis on cost. 

First, the committee does not operate with any ceiling on the cost per unit of health gained that would limit how expensive care can be and still be covered. Second, when a high quality of evidence combines with a major positive health effect supported by the evidence, cost drops out of consideration. It becomes a factor only when the quality of evidence is low, and/or when the comparative effect that a treatment achieves is small. 

The future of Washington’s efforts to prioritize services for state-funded coverage based on comparative effectiveness review may thus be bright even while the politics of prioritization elsewhere are vicious. 

Paul T. Menzel, Ph.D., is a professor of philosophy at Pacific Lutheran University. His research focuses on health care ethics and health policy, and he is the author of Strong Medicine: The Ethical Rationing of Health Care. The author is grateful for important assistance from David Pringle, Counsel, Office of Program Research, Washington State Legislature.  menzelpt@​plu.​edu; 360–969‑2760.