Friday, May 27, 2011

Undeniable, Yet Impossible

This opinion piece in the NYT makes a compelling case for the role of medical effectiveness research. To me, the need is obvious. Maybe, in fact, it's obvious to everyone on some level. But that's not the question.

Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:

• Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them ....


• Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. .... Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.


• A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation. (note from your blogger: I wrote about this some time ago.)

The full extent of Medicare payments for procedures with no known benefit needs to be quantified. But the estimates are substantial. ... $75 billion to $150 billion could be cut without reducing needed services...

After discussing the factors at play (other examples of procedures were given, too) the author, a professor of cardiology, concludes:

Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view. (My emphasis.)

Of course, doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.

(Some time ago I proposed that if people insist on having procedures that have virtually no chance of helping, they should agree in advance to bear the full costs if it doesn't, as predicted, work. The payor (Medicare) would pick up the tab if odds were defied and there was benefit. I was being only partly facetious. Anyhow, I can't find the post at the moment. But it's my solution to the "no obligation to pay for it" issue.)

The question is not whether we need effectiveness information as we debate the costs of health care. It's the one raised at the end of the article: in the exceptional USA USA USA, the world's most exceptionally great exceptional democracy, can we find the political will, the political honesty; can we get past the ubiquitous rhetorical gamesmanship and unendingly divisive cowardice that has become our political norm, realistically to address something of such importance? In the halls of Congress as currently constituted, on the airwaves as currently polluted, can anyone imagine such a serious issue being addressed seriously, by serious people, without lies and distortions and demagoguery and political point-scoring, to try to find a serious solution?

I can't.


Anonymous said...

Jeez Sid, your gettin fewer comments than when a Black Dude cuts in line at the Lotto counter....


tome said...

Great post!

Behaviors that get rewarded will continue-push the lever get a pellet encourages the simplest of creatures.

Shocking (Oops) that patients who will not benefit from ICD's still get them-wonder what Kaiser or Mayo's rate of implant is? Wild guess, less than the MCare rate?

Suggesting that personal responsiblity has a REAL role in controlling healthcare costs is a conversation long overdue. Sad but true the conversation must start with Congress whose members in the interest of preserving/advancing their careers will pass.

On the subject of the ICD's, the entities that take the real hit are the hospitals which have almost no ability to stop in appropriate use. Compound that with Cardiologists who serve as Medical Directors for various device makers and you have a great recipe for misuse of technology.

"I get paid therefore I do"

Anonymous said...

WTF do Kaiser or Mayo have to do with IUD's?? They were hard to find 20 years ago when I tried to talk my Wife into gettin one...
Ended up gettin a Vasectomy(Me, not my Wife)pretty benign procedure if you don't count that "Getting Kicked in the Balls" feeling.
and Cardiologists don't put in IUD's OB/GYNs do, if you can find one that even knows what the F they are, asked this sweet young thang the other day if she put them in and I might as well asked her if she knew what an LP was...
So do us all a favor and remain silent if you're ignorant.


Sid Schwab said...

Good one, Frank.

Anonymous said...

I guess everyone has forgotten how many IUDs perforated the uterus of the woman they were implanted in.

The massive infections - the big lawsuits - the recalled devices.

Your wife was lucky not to have had one Frank.

Too bad about the balls, but you probably didn't need them much anyway!


tom e said...

I just reread my post-I do not see the reference to IUD's that you suggest
Suggest you follow the advice given

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