Comments on: The OTHER Health Care Crisis…

By: Charlie Baker

Charlie Baker — Tue, 12 Jun 2007 16:20:33 +0000

All - there are some conversations in Washington, DC concerning a public/private approach to studying and signing off on new medical technologies. The overall approach would have some kind of independent, national entity engage on several fronts…
1) Prioritze technologies for evaluation;
2) Review data on comparative effectiveness (this is the big missing piece - most of what happens now only studies whether something new is better than nothing - not whether or not it represents an improvement over what’s already available);
3) Fund studies on comparative effectiveness;
4) Develop an accepted framework for including cost effectiveness and other values into assessments (this would ultimately affect Medicare, private payors, and probably Medicaid, too);
5) Develop a lexicon for summarizing the findings (much like USPSTF did with respect to the level of evidence available to support screening recommendations.

We shouldn’t underestimate the difficulty in this. We’ve tried to do technology assessment before at the federal level, and when the assessor says some technology isnt’ much of an improvement on what’s already available, it generally gets de-listed from the next federal appropriation (witness the demise of the Office of Technology Assessment). This is, obviously, a big deal if this entity makes decisions - as it will - that affect what gets paid for and how.

My guess is that most of the research would be done by clinicians - as it should be - but it will still generate noise, controversy, etc. It won’t be perfect, and it will have to change over time. But we need something like this, and other countries have already proven it can be done.

By: leanne berge

leanne berge — Tue, 12 Jun 2007 01:04:40 +0000

So, what’s wrong with the NYTimes anyway? I’m not usually a WSJ kinda gal, but, they do have some good articles about health care as does the NYTimes. Beats Michael Moore.

By: Ian M

Ian M — Mon, 11 Jun 2007 18:47:06 +0000

There was an interesting report released last November by the GAO dealing with Medicare’s ESRD reimbursement policy. It puts forth the case that there is a measure of cost control to be gained from bundling payments for separately billable medications to the payments for all ESRD services. An interesting twist to this specific issue is that the measure has enjoyed relative success despite market competition for the one dominant medication (Epogen) used to treat the disease. This issue is also tied to some of the end of life and societal topics that BC touches upon. Here’s the link:
http://waysandmeans.house.gov/media/pdf/healthdocs/120506gaorpt.pdf

By: BC

BC — Sat, 09 Jun 2007 11:48:13 +0000

Paul – Several insurers tell me that they are moving toward trying to reward quality and cost-effectiveness. UnitedHealth Group, for example, claims to be able to identify providers who achieve above average outcomes and/or are more cost-effective. United awards them a premium designation and members are encouraged to use them. Wellpoint has identified better hospitals as Centers of Excellence for cardiac care, gastric bypass, organ transplants and, soon, oncology. Cigna claims to be able to identify the best practicers vs the high utilizers and is prepared to reward the former with somewhat higher reimbursement rates.

Where I think only the government can provide leadership is in saying NO. It might refuse to pay for a new biotech drug or medical device that cannot pass a QALY threshold. It could decide that we, as a society, cannot afford and should not pay for surgical interventions for patients with advanced dementia or Alzheimer’s. Or, as they do in the UK, refuse to pay for kidney dialysis for patients beyond a certain age. Same for hip and knee replacements, angioplasty, CABG, etc. The issue is not do we reward quality or market share; it’s who has the moral authority to say that we can’t afford to give everything to everyone, and we have to draw the line somewhere. If anyone is going to make these judgments, it should probably be a politically independent government body of experts modeled after the Federal Reserve System, not the insurance industry which many people think already has too much self-interest to deny care.

By: David Harlow

David Harlow — Sat, 09 Jun 2007 01:22:52 +0000

Doesn’t every payor already have a series of coverage policies in place, informed largely by research on safety, efficacy and cost-effectiveness of the service in question? Is this not some form of EBM? (And many, but not all, coverage decisions track Medicare policy.)

See WSJ Health Blog post (and comments including mine) on the NYT article here:

http://blogs.wsj.com/health/2007/06/06/health-care-reform-you-cant-always-get-what-you-want/

David Harlow
HealthBlawg

By: Dori

Dori — Fri, 08 Jun 2007 14:42:05 +0000

A national best practices institute is an idea which educated patients would welcome due to the constant back and forth research on many medical issues. If you keep up with the news and read every new study, the contradictions are overwhelming.

As a note, the Medicare agency pilot project results published this past week show that pay-for-performance does not generate a significant improvement in quality or mortality rates. Again, this is one study, and I’m sure more will follow.

By: Ian M

Ian M — Fri, 08 Jun 2007 13:30:46 +0000

To Dr. Miller I would ask: couldn’t a separation be made between the continued study of conditions and the advancement of treatments for them? In other words, it’s obvious that our understanding of many conditions will grow as time moves forward, but does that increased knowledge always have to be tied to an urge to develop a new technology based on the most recent data?

Mr. Levy, I think that Medicare needs to provide the leadership on price control, not alternate forms of coverage. Medicare is the only single body large enough to have any lasting effect on costs, and for private insurers to take this on without the lead of Medicare would be risky, and require an enormous amount of collaboration. I think both parties (the government and private insurers) will be a part of the ultimate solution. I think BC is correct to be wary of the classic concept of universal coverage that many of the Democratic candidates are advocating. The design of the MA HealthCare Reform policy is a great example of the government and private sector tackling the issue on a smaller (but still very large) scale. Hopefully, with the Quality and Cost Council up and running and having a positive impact, the state could prove to be a model to follow on a larger scale.

By: anonymous

anonymous — Fri, 08 Jun 2007 13:15:20 +0000

Taking a contrarian view, one person to which I mentioned the disparity in the Idaho and Maine results replied “well, there are more farmers in Idaho and they ruin their backs.”
Just keep in mind there is more than one explanation for any finding, and that’s why this issue is so complex.

By: br

br — Fri, 08 Jun 2007 13:12:42 +0000

I agree with Dr. Miller, and please don’t consider this just sour grapes by physicians. There is a real danger of “group think” when there is a national best practices institute, because anyone who disagrees or doesn’t use those practices opens themselves up to a problem both legally and financially. Hence the fears of “cookbook medicine” on the part of physicians. Also, many studies conflict depending on their statistical methodology or population selection, and a consensus may not emerge for years.
As an anecdotal example, take the menopausal hormone issue. For years, physicians almost automatically offered hormones to any menopausal woman. The surgeon I see for annual breast exams did so to me a couple years ago, and I explained to him that, being a pathologist, I was seeing fibrocystic-like changes in breast tissue from 80 yr old women, both at autopsy and in surgical material. (This is not normal and can be precancerous). I told him that my personal theory was that these changes were probably related to hormone therapy, and that there was no way on earth I was going to take hormones. Less than a year later, these studies showing a relationship between hormones and breast cancer emerged. Could be coincidence, of course, but there are thousands of things out there in medicine that an observant practitioner notices, that are just not studied by the medical establishment, for one reason or another.

Having said that, I am still in favor of Charlie’s idea; I just think it needs to be carefully structured and not used as a club or as an excuse.

The most important part is to include all parties in an open and collegial debate on this giant issue, and refrain from blaming any one of them for the current situation; and that all parties approach the debate with a wider view than their own self interest.
Unfortunately, the chance that it will happen like that is like the proverbial snowball in hell.

By: Michael D. Miller, MD

Michael D. Miller, MD — Fri, 08 Jun 2007 12:25:20 +0000

While “evidence based medicine” is a great concept, applying it has significant challenges and dangers: First, what was the “best” way to treat a condition 3-5 years ago because by inherently the evidence to make these assessments is at least that old. Therefore, advancements in care made since they are not included in the EBM guidance. Second, there is the danger that EBM assessments will be used as rhetorical cover for decisions to cut costs or use the least costly alternative. The VA has did a marvelous job of this when they started their national formulary, and CMS/HCFA has done this cost estimates of proposed benefit changes. And lastly, any EBM/cost-benefit analyses can be biased because of who what populations they are examining, i.e. who pays v. who benefits, etc.