“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?
*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*