The bean counter will see you now
Medical researchers and politicians are tiptoeing into an area of healthcare that makes some Americans uncomfortable, even angry, and it has nothing to do with such hot-button issues as cloning and stem cell research. This time, the controversial idea is to press doctors and patients to use particular drugs and treatments in order to save money.
On the surface, it seems simple enough: Billions of dollars could be saved if everyone adopted the regimens that research showed were best and most cost-effective -- which, experts say, happens far less than most patients think.
The problem is that any push for doctors and patients to make a particular choice collides with the cherished American belief that medical decisions are nobody’s business but the patient’s and the doctor’s. Least of all the government’s.
Also, since the research is based on statistical analysis and almost all medical choices involve trade-offs, the “best practice” is sometimes arguable.
Yet scientists, medical policy specialists and leading politicians are starting to embrace the idea of using cost-effectiveness research to drive individual medical decisions. They call it “comparative effectiveness” research, sidestepping a direct reference to costs.
Democratic presidential candidate Sen. Barack Obama of Illinois is calling for substantial investment in the idea. And GOP candidate Sen. John McCain is interested.
Sens. Max Baucus (D-Mont.) and Kent Conrad (D-N.D.) are to introduce legislation to create a government institute for such research. Baucus heads the finance committee, which oversees Medicare and Medicaid, and Conrad heads the budget committee.
Americans are expected to spend $2.4 trillion on healthcare in 2008. Within a decade, the figure is expected to surpass $4 trillion a year and account for 20% of the gross domestic product, the prime measure of economic output.
Using the information
“Learning how to spend smarter is one of the three or four critical things that needs to happen in our healthcare system,” says Gail Wilensky, a leading Republican health policy expert and former Medicare administrator. “Not only is it something the Democrats have been interested in, but a number of Republicans think this is the kind of information that is consistent with market strategies [to reform healthcare] that help doctors and patients make better decisions.”
Obama’s plan to control costs and make insurance more affordable includes an institute to study cost-effective treatment options. McCain’s healthcare advisor says a greater role for cost-benefit studies is “imperative.”
The candidates say their sole purpose is to generate information to help doctors and patients make better decisions -- not to steer insurance coverage. But experts say that’s exactly where the process leads: First, researchers would identify “best practices,” then Medicare and private insurers would come under pressure to penalize those who rejected the guidance.
Initially, research would probably focus on treatments that have not yet been widely adopted. But common treatments debated within the medical community -- such as surgery versus physical therapy for bad backs -- could also get scrutiny.
In the future, some experts say, approved medical tests and treatments could be handled the same way prescriptions drugs are: Patients would pay little or nothing for generic drugs or “high value” procedures and higher co-payments for treatments judged to be of “low value.”
Medicare does not explicitly take costs into account. It bases coverage decisions on whether a new treatment is “reasonable and necessary.” Supporters of adding cost considerations to the equation -- using “comparative effectiveness” research -- say the goal is to develop a knowledge base that government programs and private insurers can rely on to guide decisions.
“People have pointed out that a lot of the care in our system is inefficient, wasteful or inappropriate -- maybe 20% or 30%. The problem is, it doesn’t come tagged,” said Sean Tunis, Medicare’s former chief physician. “So any efforts to restrain spending on unnecessary care are going to involve difficult decisions depriving people of things they need, or think they might need. We haven’t been very honest about it, and we haven’t figured out a good way to do it.”
A case study
Prostate cancer, which occurs in older men and will become a bigger problem as baby boomers age, illustrates both the potential savings and controversy of the “best value” approach.
If the cancer is discovered early, doctors and patients have several options. They can choose “watchful waiting” to see how the normally slow-growing tumor progresses. Chemotherapy is another possibility. But radiation is increasingly the choice because side effects are fewer.
Three-dimensional CT scans are used to focus X-rays on the tumor while sparing surrounding tissue.
Over the last five years or so, a form of radiation known by its acronym, IMRT, has become practically standard in this country.
But recently a panel of scientists, including Tunis, conducted a study comparing IMRT with an early radiation regimen called 3-D CRT.
The study was sponsored by the Institute for Clinical and Economic Review, which is affiliated with Harvard Medical School. Director Steven Pearson is a former primary care doctor who used to yearn for data to help assess the benefits, risks and costs of different treatments for his patients.
The panel analyzed voluminous medical studies on the two treatments. The conclusion: They were about equally effective at zapping tumors and preventing recurrence.
But IMRT costs about four times the older approach: $42,450 versus $10,900.
An opportunity to save precious healthcare dollars? Yes, the panel concluded: IMRT was a “low value” choice.
But wait, some critics say, long-term effectiveness is not the only consideration. Treating prostate cancer with radiation can damage healthy tissue near the tumor. That sometimes inflames the digestive tract and can cause pain and diarrhea -- side effects that can last weeks or months.
The research showed that this occurred much less often with IMRT, which can target the tumor more precisely. About 1 in 7 patients developed such a problem with the older treatment, compared with fewer than 1 in 20 with IMRT.
Researchers were not indifferent to that, but they calculated that given the infrequency of the side effects under both treatments, it would cost $300,000 to prevent one case of bowel inflammation by using IMRT.
Faced with the need to rein in medical costs, the researchers concluded that 3D-CRT was a better choice.
“As consumers of healthcare, we have to be more clear about what we want,” said Pearson.
“We want to be clear that we are willing to pay for significant innovations, but we are not willing to pay any price for something that is just as good as what we are doing, or just a teeny bit better.”
What makes such an approach controversial is that in particular cases, individual patients and their doctors may not see it that way.
Dr. Andre A. Konski, a radiation oncologist who participated in the prostate cancer evaluation, said he had treated patients with both kinds of technology and concluded IMRT was superior.
“I have seen patients have less side effects, and you are able to go to higher doses,” said Konski, who is affiliated with the Fox Chase Cancer Center in Philadelphia. He thinks higher doses could bring higher survival rates, though the study found no significant difference.
‘The big hurdle’: money
Still, Konski agreed that the U.S. healthcare system needed a way to determine new technologies’ worth before adopting them.
“The one thing that is the big hurdle is finding the money to do those studies,” said Konski.
“There has to be money from the government.”
Republican healthcare expert Wilensky has proposed a federal agency with to fund effectiveness research, with a budget of as much as $5 billion a year.
Viewed in the context of the $2 trillion Americans spend on healthcare, Wilensky said, it would be a prudent investment.
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ricardo.alonso-zaldivar@latimes.com
