Friday, March 25, 2011

The Peter Pan reaction to controlling health care costs

The New York Times reports on Washington state’s efforts to “to determine which medical devices and procedures Washington will cover for state employees, Medicaid patients and injured workers, about 750,000 people in all.” An expert panel, appointed by the state, is getting national attention, writes the Times, “in part because its process is public and open. . . [and] provides a living laboratory of the complexities of applying evidence-based medicine, something that is becoming more common as a way to rein in health care costs.” The American College of Physicians, in its policy paper on Conserving Health Care Resources, similarly called for a transparent process to allocate resources based on evidence: ACP wrote:

“There should be a transparent and publicly acceptable process for making health resource allocation decisions with a focus on medical efficacy, clinical effectiveness, and need, with consideration of cost based on the best available medical evidence. The public, patients, physicians, insurers, payers, and other stakeholders should have opportunities to provide input to health resource allocation decision-making at the policy level.”

So, how is that working out in Washington? Well, according to the Times, although many of the expert panel’s recommendations have generated little controversy, the panel’s decision to limit coverage for spinal injections to control pain was compared to “waterboarding and other forms of torture” by a medical journal editorial writer.

I don’t know whether the panel got it right about spinal pain injections. But the Washington state efforts shows the obstacles that will face any effort to limit coverage of medical treatments, even when done in an open and transparent manner with broad publication:

- Personal stories of patients who claim to have been helped by a particular medical intervention will carry more impact than evidence from clinical trials. Clinical trials are dry, technical analyses that most of the public doesn’t understand. But a patient being denied treatment for something that they swear helps them will trigger an evidence-be-damned reaction from much of the public.

- Medical device manufacturers have a vested interest in preserving access to their products and will not go quietly into the night. They will seek to ally themselves with patient advocacy groups and physicians who specialize in particular treatments to blunt any effort to deny or limit coverage. And they often will prevail.

- The experts making the determinations will be attacked for not having the required expertise—meaning that unless they actually perform the procedures being evaluated, it will be said that they don’t understand it and therefore aren’t qualified to issue a ruling. The counter-argument is that physicians with expertise in review of medical evidence don’t have to be trained in a particular procedure to assess the strength of the evidence. And, packing panels with specialists that have a vested interest in maintaining access to a procedure that they perform creates an obvious potential for conflicts of interest. But I expect that much of the public will buy the argument that only those physicians who perform a procedure are qualified to rule on its effectiveness.

David Leonhardt, in a January New York Times Economix blog, compared the public’s views on rationing to Peter Pan’s wish to stay a child forever:

“Opposition to health-care rationing is a little like opposition to growing up. It sounds great. It’s just not very practical.”

It seems to me that Washington state deserves credit for trying to have an adult conversation about how best to allocate limited resources, but is facing a Peter Pan reaction by much of the public and medical profession to its decisions.

Today’s question: What do you think can be learned from Washington state’s experiment?


Steve Lucas said...

I could not help but be reminded that after WW II medical insurance was used as an incentive in recruiting manufacturing workers. This insurance then kept pace with medical advances and soon took on the position of a “right.”

In Europe after WW II there were masses of displaced people and a requirement to rebuild infrastructure. Social programs, and society itself, were structured to accomplish this task. Medical care was viewed as a “need.”

This point was driven home again as my wife and I just returned from our yearly trip to France. Time and time again we were told medical care was a government function, with an associated “cost.” This “cost” was associated with fulfilling a “need” for a basic level of care, not the “right” for unlimited use of medical resources.

Over the last 65 years we in the US, with no visible contact with “cost”, have morphed medical “need” into a “right,” driven in great part by those in various industries who will profit from this concept.

Washington State is trying to define the concept of “right” and balance it with “need” in order to control “cost.” Given the financial incentives of those involved they will find it difficult to see any short term gains, as a common tactic in these situations is to delay any decision, while those involved continue to reap profits.

Those receiving all of the benefits see no reason to have the adult conversation as it is a win win for them to simply stop the process. Those who are paying for those benefits are painted as throwing grandma under the bus. The adults are going to have to stay the course, and remind those involved who is paying their allowance.

Steve Lucas

Jay Larson MD said...

You do not need to be a specialist to determine outcomes. Many outcomes are easily measured with today’s standardization techniques…quality of life measures, walking distance, pain scores, longevity, event reduction, relapse reduction, etc.
What should be better studied are the risks and benefits of a procedure or treatment before it is released on the general population. There are many examples throughout history in which benefits never panned out. Autologous bone marrow transplants for breast cancer is a good example. I have had several patients who have had spinal cord stimulators for pain that have not significantly benefitted from the device. More of my morbidly obese patients failed lap bands, than have benefitted. Look at the medical devices that have been recalled or determined defective …pacemakers, artificial heart valves, and hip prosthesis. Then there are the pharmaceuticals that are taken off the market because once released into the general population, concerning side effects were found…Vioxx, Baycol, Rezulin, Propulcid, Seldane to name a few.
Yes, there are “personal stories of patients who claim to have been helped by a particular medical intervention will carry more impact than evidence from clinical trials”. What also needs to be heard are all the other stories of people undergoing the medical intervention in which no benefit or more importantly harm occurred. If any panel is taking on the challenge of “limiting” medical interventions, they need to be armed and present all the data. When the data is presented to the public, it should be presented in easy to understand terms. Rather than telling the public that there is a 50% risk reduction for a primary event. Just lay it out simply… Out of 100 people receiving an intervention, 2 people did not have an event because of an intervention, 2 people had the event despite the intervention and 96 people were not going to have the even anyway.
“Packing panels with specialists that have a vested interest” has already been shown to fail the public. Just look at the RUC and the current value system used for reimbursement. Knowing that there are limited resources in the system, new procedures kept getting added with high values without regard for the effects on E and M payment outcomes. Even the designer of the RBRVU system warned that letting the AMA and specialty societies take over the value system was a conflict of interest and would result in unfavorable outcomes.

ryanjo said...

Yes, I admit to being one of those "Peter Pans" who opposes health care rationing.

You see, I have experience with this type of rationing panel. Almost every day, I am called away from a patient encounter to answer a call from an insurance company doctor, questioning my decision to order a test or treatment for patient about which they know little. But they make a decision anyway. The sheer volume of the task allows for a very limited grasp of the patient's condition. Why would anyone think that these proposed panels would have the time to do any better?

I oppose these panels because they are more damaging than the status quo. The real problem in allocating resources is to reform the system. PCPs with enough time to explain & discuss. Thought valued more than tests or procedures. Patients back in the decision process by taking financial and personal responsibility for decisions.

But in Arizona & Washington state, and soon elsewhere, our policymakers have decided to put another disconnected layer of decisions over an inefficient system.

But who am I to disagree. Pundits at the ACP have decided that an "acceptable process" is needed. The New York Times has already labeled any opposition to rationing infantile (always interesting when an opinion columnist feels the need to pump up his argument with ad hominem labels.) So much for an "adult conversation".

Kathy said...

Allocation of scarce resources is always done best by free markets ( which we do not have). Safety nets are fine, but everyone in the safety net is stupid. Econ 101, supply and demand. Health care is too important not to have benefit of free market economics. Interfering government policy has caused perverse incentives, price escalation, scarcity, poor value, dissatisfaction amongst physicians, lack of true insurance options, etc.