NAIRO Guide Helps Define the Importance of Evidence-Based Medicine

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How Independent Review Organizations Promote Coverage of Safe, Research-Based Services - New Guide Released by NAIRO on Evidence-Based Medicine

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This guide will:

  •     Define evidence-based medicine.
  •     Describe how evidence-based medicine is used in the health care system.
  •     Explore the role of independent review organizations with regard to health insurance denials.

At first glance, the term "evidence-based medicine" may sound complex. But really, it's a very simple concept: The goal behind evidence-based medicine is to use health services and procedures (such as surgeries, the use of prescription drugs, etc.) in a way that positively impacts a patient's health and well-being.

When it is boiled down, the term combines two main elements:

  •     Evidence, or the use of data, research, studies and knowledge patterns; and
  •     Medicine, or the services that a person receives from a doctor, surgeon, pharmacist or other healthcare professional.

Put together, evidence-based medicine is a way of providing health care services that are proven to be effective. Such services are based on studies that show clear benefits for a patient's health and well-being.

Today the use of evidence-based medicine continues to expand throughout the health care system. As we will see, using evidence-based medicine as a guideline can protect the health outcomes of patients.

Defining Evidence-Based Medicine
Evidence-based medicine is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." -Dr. David Sackett, 1996

Health Reform: More Evidence, Better Care

The Patient Protection and Affordable Care Act of 2010 (commonly referred to as the "Health Care Reform Law") promotes the use of evidence-based medicine in a variety of areas. One of these areas is known as "comparative effectiveness," which, simply put, is a way of showing how well a certain health care service (such as a specific procedure or medication) results in positive outcomes in a patient, as compared to the results of other types of services for the same diagnosis.

For example, "comparative effectiveness" research may compare two types of procedures for breast cancer treatment, and it will tell us which one provides the best results. The foundation of this type of comparison between the most effective health care services is, in fact, evidence-based medicine, according to experts.[1]

Health reform has created new ways to use data to help consumers access safer care. As one doctor put it, "Health care reform will provide a robust environment for comparative effectiveness research, systematic reviews, and evidence-based medicine, and implementation of evidence-based medicine should lead to improved quality of care."[2]

There are thought to be many benefits in using evidence-based medicine, not least of which are more options for consumers who use health care services because of illness or injury, as well as improved quality of life and clinical outcomes.[3]

As the use of evidence-based medicine spreads throughout the health care system, one area that can provide clear benefits to consumers is in the area of the health insurance system, which uses evidence-based medicine to determine what services will be paid for.

Health Insurance: Gaining the Best Coverage

We have all heard stories, whether from a friend or family member, about how a health insurance company denied coverage for a health care service (like a test, surgery, medication or other procedure). When that happens, the person in question may have to pay for the health service with money out of their own pocket, which in some cases can be very expensive.

However, it is important that consumers know that the decision of the insurance company to deny coverage of a certain service is not necessarily final. In other words, consumers can appeal the decision; if the health care service they received is appropriate, then the insurance company may be forced to cover it (i.e., pay for it). This is where evidence-based medicine comes into play. It can help ensure that patients receive insurance coverage for services to which they are entitled under their respective health insurance service plans.

A key part in all of this is the role of an independent review organization (IRO), which can have final say about whether a patient's service must be covered by their insurance company.

What Does an IRO Do?
An independent review organization, or IRO, delivers impartial judgment on an insurance company's decision not to cover a certain health service or treatment for an enrollee. The enrollee, after completing or “exhausting” his or her internal appeal process, has the right to file for an independent external review with an IRO. The enrollee should consult their insurance handbook to fully understand how the external review request process works, specific to their form of insurance coverage.

If the enrollee is eligible for an external review the insurance company is required to send the enrollee’s case file to an IRO. The IRO will select a peer reviewer in the same or similar specialty as the enrollee’s treating provider to perform the external review. The IRO’s peer reviewer is required to base their decisions on evidence-based medicine, best practices, and the current standard(s) of care. While this does not always ensure a reversal of the insurance company’s denial, the use of evidence-based medicine in the external review, at a minimum, provides the enrollee with an independent review performed by a qualified provider relying on the most current medical information.


1. Evidence-Based Medicine. National Pharmaceutical Council. Accessed December 13, 2012.
2. Hughes, GB. Otolaryngology-Head and Neck Surgery. 2011 Oct; 145(4):526-9.
3. Introduction to Evidence-Based Practice. Duke University Medical Center Library and Health Sciences Library, UNC-Chapel Hill. Accessed December 13, 2012.

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