Saturday, February 28, 2009

Wise Words about Medicare

I've taken the liberty of copying an editorial from today's New York Times. (Having been born in New York City I used to assume that all literate people read the Times!)

Medicare sets the overall direction for U.S. health care policy. I inserted numbers into the text to indicate points I comment on below:
Evidence and Health Care Reform
Medicare has proposed not to pay for so-called virtual colonoscopies because there is not enough evidence that they would benefit people aged 65 and older. That may be disappointing for older Americans who would prefer a virtual exam to a real one. (1) But those sort of judgments will be fundamental to any successful health care reform effort. Eliminating unproven procedures and reducing needless costs is necessary if the nation is to improve the quality and lower the cost of care over all.(2)

In a standard optical colonoscopy, a doctor inserts a long, flexible tube with a tiny camera at its tip into a patient’s rectum and colon. In a virtual colonoscopy, the doctor uses CT scans to produce images of the colon’s interior. If worrisome polyps are spotted, the patient then has to have them removed by a standard colonoscopy. Although a bowel-cleansing preparation is required in both kinds of colonoscopy, some patients are thought to prefer CT scans because they are less intrusive.

Some medical organizations have recommended virtual colonoscopies as an acceptable screening tool for colorectal cancer while others have found the evidence insufficient. Some insurers cover them; others do not. The CT scans detect larger polyps about as well as optical colonoscopies but are less effective at detecting smaller polyps.

Medicare’s concern is that older patients are more apt to have polyps than the average American. No studies have focused on how many Medicare patients who get virtual colonoscopies would then have to have polyps removed through a standard colonoscopy. If the number is large, the initial virtual colonoscopy will have been a waste of time and resources and will have subjected the patient to radiation that could have been avoided.

Medicare’s proposal is open for comments and the submission of further evidence before the proposal becomes final. Even if Medicare decides that virtual colonoscopies are clinically effective, it would then need to determine whether they are cost-effective compared with other screening options. They do not appear to be at current prices.(3)
(1) "Disappointing" is the key word here. Prudent management of the health system will entail disappointment. There's no way around it. Political leaders need to "inoculate" themselves against the backlash triggered by disappointment. In the U.S. we tend to believe that disappointment signals unfairness. It doesn't.

(2) Obviously "eliminating unproven procedures and reducing needless costs is necessary" for an affordable health care system. The most important thing about this sentence is its vagueness. Comparative clinical and cost effectiveness information won't manage the health system on its own. Some doctors and patients will follow it but lots will not. A viable Medicare system will constrain the autonomy of physician-patient dyads. In the past organized medicine has liked to claim "only the doctor can judge what is right for the individual patient." Two decades of research on unjustified clinical variation shows that this claim is false. Health care reformers will have to confront the hallowed U.S. sophism about "physician autonomy."

(3) This bland sentence has explosive potential. In its quiet way it is acknowledging the obvious. We need to ration. Every health system rations. The only question is whether it is done thoughtfully, as in the U.K., or cruelly, as in the U.S. The Republican sound bite machine is already waving the sword of the "R" word. Here's a quote from Republican House Leader John Boehner's website:
One of those [health care reform] proposals – dubbed “comparative effectiveness” – would lay the groundwork for a government takeover of American’s health care system by creating an organization to decide how to ration medical treatments. That’s right, congressional Democrats plan to “stimulate” the economy by reducing options for patients and doctors.
The health care reform process is sure to be nasty and brutish, but unlike Thomas Hobbes' prediction, it probably won't be short.

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