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 ....

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• 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.