Wednesday, July 30, 2008

Joint Replacement, Medicare, and the Ethics of Arrogance

Our national failure to establish a registry to track the performance of artificial joints points to a little discussed value that drags down the quality and efficiency of U.S. health care – self-satisfied arrogance.

The trigger for this posting is the latest article in a New York Times series on the “evidence gap” – treatments purveyed in the absence of persuasive evidence that they work.

Here’s the story. Artificial joints are made by different companies. The devices vary in their performance. Some do better with one patient group and worse with another. New devices are introduced with hope and hoopla. Eight years ago 3,000 patients received a hip implant that caused terrible pain for many before it was removed from the market. (It turned out that the implant had been contaminated by oil during production. In the face of enormous claims, the company filed for bankruptcy.)

This would not have happened in Australia, Britain, Norway, or Sweden, which track the performance of implanted joints. Perhaps 40 – 50 would have received the new joint before its failure was identified. Not 3,000.

The idea of systematically tracking the performance of new kids on the block in medicine is a no-brainer. There is everything to say for it, and little against it other than the effort it takes to do the right thing.

So what’s going on here? Are we too stupid to see the obvious?

The problem isn’t stupidity – it’s arrogance. How often have we all heard that we have the best health care in the world? American exceptionalism – the belief that we are different, and better, than all others, and have nothing to learn from them, runs deeply in our national soul. With artificial joints, arrogance shows up in our assumption that the claims of U.S. companies about their products must be true, and that the opinion of an individual surgeon is an adequate monitoring system.

Our absurdly fragmented health “system” makes creation of a registry more difficult. Organizations like Kaiser Permanente can track their own experience. But the most obvious venue for initiating the registry process is Medicare.

That's the most distressing part of the story. The U.S. performs half of the world’s joint replacements, and Medicare pays for half of the implants. But two years ago Medicare turned down a proposal to create a registry, with the rationale that it was not the agency’s job to collect the data.

Medicare’s response to the registry proposal reflects the same stifling potential of bureaucracies that was at work when the Federal Office for Human Research Protections initially squashed wider application of the ICU checklist program (read about it here).

Conflict of interest obviously plays a large part in our failure to monitor the performance of our health care non-system. There is so much money to be made by manufacturers, hospitals, and practitioners. Careful scrutiny of results could block the income flow.

But conflicts of interest are omnipresent. If we didn’t start from a stance of arrogance – the smug conviction our health "system" is the BEST – we would confront the conflicting interests and seek out the facts.

"Evidence-based medicine" is a popular slogan. But it won't have meaning in action as long as we remain wedded to our near delusional belief in the excellence of our health care "system."

I think the most practical suggestion as to what we should do is found in Maggie Mahar's recent "Health Beat" posting on Medicare. Jeremiads against arrogance don't create change. But we can all see the writing on the Medicare wall - without reform, this most popular national program will go broke. Mahar urges Congress to make Medicare a demonstration program for effectiveness and efficiency. Doing this could be framed as a piece of responsible bipartisan governing. It doesn't require a national mea culpa about arrogance. Once we make collecting information about effectiveness and safety a routine expectation in health care our value set may shift from arrogant faith to empiricism.