Thursday, June 9, 2011

Should taxpayers pay for unnecessary care?

“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.”

So argues Dr. Rita Redberg, a cardiologist and professor of medicine at the University of California, in a provocative op-ed published in the New York Times. She writes that Medicare “spends a fortune each year on procedures that have no proven benefit and should not be covered” and offers the following examples:

“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 (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure.”

“The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.”

“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. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.”

“Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death . . . Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.”

“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.”

If Dr. Redberg is correct that these interventions offer no benefit, why then does Medicare continue to pay for them? She offers several explanations: the contractors who process Medicare claims have no incentive to clamp down on unnecessary procedures, denying payment after a procedure is performed “invites the wrath of both patient and physician” and “our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test.” (I would throw in defensive medicine as another factor.)

But for Medicare to pay only for care that is necessary and effective, as Dr. Redberg favors, more research will have to be done on the effectiveness of different treatments, and Congress would have to allow Medicare to use such evidence in making coverage determinations.

As a first step. the Affordable Care Act creates a new public-private institute to fund research on comparative effectiveness, but prohibits such research for being used to deny coverage based on cost or to “ration” care. Even so, some conservative lawmakers want to cut off government funding for the institute because they “do not believe that the government can rationally measure effective and ineffective treatments and steer funding away from the latter to the former.”

It is hard to see how the country can make progress to reduce Medicare costs when even a small first step get the evidence on what works and what doesn’t is under political attack, and when denying coverage “invites the wrath of both patient and physician.”

In the meantime, Medicare will continue to “squander” taxpayers’ money by obligating them to pay a fortune each year on procedures that have no proven benefit. If this isn’t the kind of government waste that should make the fiscal conservatives’ blood boil, I don’t know what is.

Today’s question: Do you think Medicare should continue to pay for care not supported by the evidence? If not, who should make such determinations?


W. Bond said...

Has the ACP taken a position yet on the "Medicare Patient Empowerment Act?"

Perhaps if informed patients can make decisions about the care they want and are willing to pay for we won't need to rely as much on central committees.

The USTPTF and the like are not "independent" for long, once their recommendations take on the force of policy and law.

I realize, of course, that patinets can already opt to sign waivers for uncovered procedures. However, if an M.D.'s labor demands market rates, the pressure to subsidize the labor with "extras" will be less.

Steve Lucas said...

The short answer is no.

My reality is that you inside and us outside medicine fight the great pharma advertising machine. This machine has conditioned the public that more medicine is better medicine and any efforts to cut back on unnecessary procedures is tantamount to throwing grandma under the bus.

A recent post highlighted a new book detailing how pharma has so deeply injected itself into medical research and publishing that almost all information is of questionable value.

A few years ago I had a very high profile debate with a well known medical blogger about the HPV mandate. Even when I pointed out there were no test subjects in the lower end of the mandated age group, and there were no cost benefits to the population, it took confirmation by a doctor to get an agreement that this may be a valuable tool, but a mandate is not a desirable objective.

We must also consider the fee for service business model now used in medicine. There is no incentive not to do something, even if we have to bend the rules. How many terminal cancer patients are given six figure “treatments” while in the ICU? I watched a friend battle an oncologist who insisted she could extend his life given his financial resources and insurance, if he would only live his final weeks in a hospital.

To make this work we will need to make some core changes in the way medicine is delivered and compensated in this country. This will take time and right now you are dealing with the “golden children” of the baby boom generation (1945 – 1950). They want it all and they expect someone else to pay for it.

Steve Lucas

Ashok V. Daftary, MD, FACP. said...

I have a responsibility for utilization management in my institution. Dr.Redberg is correct. The waste of medical resources is tremendous, laboratory "panels" designed to facilitate work flow are applied indiscriminately. CT scanning has replaced the processes of talking to a patient or touching them.
Panels incorporating tests that hane a high incidence of false positives lead the user to a medical never-land.
We have an abuse of technology often for self-profit. When unnecessary procedures are deliberately performed they constitute professional fraud.
The answer is not education but incarceration.
This will send a chilling message to curb such practices.

Leonidas300md said...

As we all know or should know , effectiveness of medical treatment is not always black and white. A recent analysis of published AHA/ACC guidelines showed over 50% were merely opinion , perhaps excellent opionion based on the available data, but opinion nevertheless.

Government run boards with political appointees will be under pressure to serve their government masters. If there is concern that private MDs working for the drug industry may be influenced in their opinions , surely there should be the same concern that a doctor appointed by a future government may also have inherent conflect of interest.

In the final analysis , the best protection for patients is to have their doctors free of any possible coersion whether it is from the doctor's relationship to a drug company or his/her relationship to a government body

Robert J. Sobel, M.D. said...

The post-hoc analysis is always so persuasive. Despite the examples chosen and many others that are possible, none of these tests are invariably or a priori unnecessary. The reality is that things are always in dynamic flux and that studies often prove post hoc what clinical practice dictated (my favorite example remains glycemic control in type 1 diabetics). There are a lot of individual realities that do not show up in large studies and in the guideline creation process. Too many guidelines would have mistreated my patients; for me to cede responsibility to the “conventional wisdom” would be the height of irresponsibility. Plus, arbitrary age cut offs just don't fit with the management of real people.

Fee for service does not represent a carte blanche, as Mr. Lucas describes. With patients both seeing the bill and paying the bulk via deductibles, co-pays, and the premium, I do not feel like most patients wish me to do as much as possible. The problem of ACO's and capitation is that the counter-incentive to do puts the MD's motivations in the direction of coerced frugality over judicious comprehensiveness.

The perpetuation of the argument that patients have unlimited desires and a spoiled, entitled point of view, is really unfair. There is a prevalent skepticism of interventionalism, over-medication, and hyper-testing, that actually leads to an under-utilization of many interventions (establishing a relationship with an internist, accepting proven pharmacologic interventions, and persisting with ongoing surveillance). The manipulated, inconsistent, and uneven “skin in the game” is not helping this.

Do I have an answer for Medicare growth, with my advocacy of physician and patient independence, even when proof of "necessity" remains a debatable point? Do I think we are better off without updated electronic records that put a warning by any woman on estradiol (recent consult letter received with the annotation, "WARNING: Hazardous drug.")? You bet.

Regulate the prices building on what is already done. Don’t adjust the global budget on the backs of physicians. Recognize how slanted the payments are currently, and retract the excesses that dominate drug and technology and novel procedure costs. That is, have the insight and discipline to ignore the interests who by design or by default will decimate independent practice. There is a built-in cost to large entities that includes our all paying for the new infrastructure, technologies, and the marketing thereof. There is the Part D, brand-generic, free-for all that remains devoid of true cost control.

We need to look at these structural costs, the ones that patient and physician have little control over. Patient realities and professionalism will prevent us from falling victim to the marginally necessary bankrupting us. Focusing on fluff will invariably cost us more through its direct interference with the greatest strength of our current fee-for-service model: flexibility, proportionality, reward for effort, and transparency. I know there are counter-arguments and I do not discount them all. When it comes to a fair appraisal, however, more bureaucratic meddling will not serve the medical common.

Until someone corrects the cost of $30,000 per year drugs and the billion dollar baby syndrome, with dollars that could support a bunch of average patients getting their whole annual health services covered, these discussions will remain fruitless in truly addressing unnecessary “costs.”