Recently in Medicare Category

MRI imaging payments - a case study in the health care reform struggle

In another fine example of its dedication to important health care journalism, the Milwaukee Journal-Sentinel published a piece, "Debate on MRI payments just one hurdle for reform."

Gems in this piece include:

  • Information on the Access to Medical Imaging Coalition, a group backed by the major manufacturers of imaging equipment, including GE Healthcare. The paper reports: "That industry backing goes unmentioned by the innocuously named group. The Access to Medical Imaging Coalition, which includes cardiologists and radiologists, is just one of the myriad special interest groups that often oppose cuts in what Medicare pays for medical services."
  • "The reality is the status quo puts a lot of money in a lot of people's pockets," said Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change, a policy research organization in Washington, D.C.

    Another reality is groups such as the Access to Medical Imaging Coalition often succeed in persuading Congress to protect their interests.


Read the entire piece. It includes local angles on local industry affected and about Wisconsin legislators' activities in this area. A fine example of local journalism on a national issue.

That quote comes from a Minnesota physician in a Pioneer Press article that includes many good elements:


  • Info on disparities in Medicare spending;

  • Dartmouth Atlas data and graphic;

  • Local angle on Atul Gawande's New Yorker piece .

20090627_070239_090628MedicareSpending.jpg

Kudos to reporter Jeremy Olson.

The Colon Cancer Alliance has distributed a statement of disappointment over Medicare’s decision not to pay for virtual colonoscopy.

Let's do a reality check on what they say in that statement.

"This decision now leaves millions of older Americans exposed to a higher risk of colon cancer.”

• Nope. Not one bit higher than it was the day before the decision was made. The risk is the same. Ridiculous fear-mongering rhetoric.

“It also exacerbates an unequal standard of care between Medicare beneficiaries, who do not have the choice to undergo a virtual colonoscopy, and those with private insurance who do.”

• Euphemism for rationing – battle cry of almost any anti-health care reform movement.

"By denying coverage for virtual colonoscopy, CMS is sending the signal that increased screening amongst the Medicare beneficiary population is unimportant.”
• Hmmm. I didn’t get that signal at all. I heard a signal of “show me the evidence in a Medicare population.” Period. There's no denial of payment for methods WITH solid evidence in a Medicare population.

By the way, the Colon Cancer Alliance is sponsored by a host of drug companies and by GE Healthcare, which makes and sells virtual colonoscopy machines.

Let's be clear: I don't have a dog in this hunt. I have nothing to gain or lose by Medicare's payment decisions - no more than any other taxpayer. But I can't stand the rhetoric. And I'm going to write about it whenever I have the chance.

Medicare makes evidence-based decision on virtual colonoscopy

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The great hue and cry about rationing and about socialized medicine has begun following Medicare's decision yesterday that it would not pay for so-called "virtual" colonoscopies.

The agency concluded that "the evidence is not sufficient to conclude that screening CT colonography improves health benefits for asymptomatic, average risk Medicare beneficiaries."

I haven't seen one news account yet, though, that actually explored in detail what that evidence was.

This was a bold move by Medicare administrators - in the face of intense industry pressure to approve the scans.

The American College of Radiology has posted a statement that says the decision will "cost lives" and mentions a study but doesn't address the very issue that Medicare acted on - evidence in "asymptomatic, average risk Medicare beneficiaries." The ACR statement then even plays the race card, saying the test "can help overcome the disparity in colorectal care that exists in minority communities."

I wish news stories and press releases would skip the rhetoric and explain the evidence. Otherwise the rationing rhetoric is bound to continue - without advancing true public understanding of the issues at play. It's another early bellwether of what any true comparative effectiveness research effort will be up against.

The virtual colonoscopy conundrum

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Good LA Times piece: "Virtual colonoscopy at center of policy debate: Will Medicare pay for the procedure even though there's no consensus about its effectiveness?" Excerpts:

In an extensive, year-long, review of virtual colonoscopy, Medicare officials scoured medical journals, convened doctors and health policy experts and reviewed more than 400 opinions submitted in two public comment periods. colo-ct-082.jpg

Though many urged Medicare to cover virtual colonoscopies, others counseled caution.

"You have to be really, really careful when it comes to preventive services because you are starting with asymptomatic people who appear to be healthy," said Dr. David Shih, senior director of medical affairs at the American College of Preventive Medicine.

...

On Feb. 11, the federal agency drew a simple conclusion: "The evidence is inadequate." It recommended Medicare not cover virtual colonoscopy.

The move sparked an immediate backlash.

"There are those who believe we have to have absolute gold-plated evidence to OK a procedure," said Dr. Len Lichtenfeld, deputy chief medical officer at the American Cancer Society. "But the fact is that we are not getting the job done when it comes to colorectal screening. . . . We have an obligation to give the benefit of the doubt to Medicare beneficiaries."

Working with a Washington lobbying and public affairs firm, interest groups organized a briefing last month for lawmakers in the Capitol.

More than 50 members of Congress mounted a letter-writing campaign to the Medicare agency.

To some health policy experts, that kind of political pressure is one of the reasons the nation's healthcare system has become so inefficient. Few expect it change, however. .

"The issue is: Who is going to make the decisions about what we do and what we don't do in medicine," Lichtenfeld said. "Let's not kid ourselves: That is a political question."

Here come the lobbyists - a hint of what health care reform faces

CQ HealthBeat reports that more than 40 members of Congress have signed a letter asking Medicare to reverse its tentative decision to end coverage for virtual colonoscopies, or CT colonographies. Last month Medicare announced its decision citing a lack of evidence that virtual colonoscopies result in improved health for Medicare beneficiaries who do not have symptoms of and have average risk for colon cancer.

This is what's going to happen at every step of any serious health care reform discussion we have in the next few years - or ever. Evidence-based decisions will be labeled as creating rationing. Government officials will be accused of practicing cookbook medicine. Critics will ask consumers, "Do you want long lines like they have in the UK and Canada?"

What fun this will be.


The crazy quilt of health care in the US

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If you want to get a picture of the crazy quilt of US health care, take a look at the new Dartmouth Atlas Project report.

It shows that:

Medicare spending is rising more than twice as fast in Dallas as in San Diego.

Medicare is spending nearly three times more on seniors in Miami than in Honolulu.

In the image below, Wausau, Wisconsin is shown with rapidly rising Medicare costs amidst a sea of otherwise lower-spending Midwest hospital regions. Why?

new Atlas Wausau.png


Or you can go to this full interactive scroll-over-your-region map.

A news release accompanying the report says:

“This illustrates how huge inefficiencies in the U.S. health care system are hamstringing the nation’s ability to expand access to care.

The authors argue that the differences in growth are largely due to discretionary decisions by physicians that are influenced by the local availability of hospital beds, imaging centers and other resources—and a payment system that rewards growth and higher utilization."

“To paraphrase a line from the gun control debate: technology doesn’t drive the growth in health care spending; people do,” said lead-author Dr. Elliott Fisher, principal investigator for the Dartmouth Atlas Project and director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice. “The good news is that in many regions, spending is growing relatively slowly. Reformers can learn from these regions and put in place policies that help them sustain what they are doing now, and encourage high-cost, high-growth regions to change their ways.”

“This work demonstrates why health reformers should work to realign private and public payment schemes to benefit quality performance over the volume of services,” said Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation. “Clinicians who successfully provide high quality care and slow spending growth should be rewarded, not penalized.”

“This is an opportunity for physicians to lead,” said Dr. Julie Bynum, co-author and assistant professor of Medicine at Dartmouth Medical School. “But even though doctors still make most of the critical decisions about how and where their patients get care, they will need help from payers and policymakers. Physicians operate under the rules of a system that is rigged to reward high-cost care.”

More maps are available online.

So is the study, published in the New England Journal of Medicine.

There's an important message for consumers here. This isn't just academic policy wonk talk. Health care consumers need to know that there's tremendous variation in the way health care is practiced in this country. There is tremendous uncertainty about best practices and best treatments. And - repeat after me -

MORE IS NOT ALWAYS BETTER - NEWER IS NOT ALWAYS BETTER - IN HEALTH CARE.


Virtually no news about virtual colonoscopy questions

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Newer is not always better. Evidence is important. Simple themes, oft forgotten in health journalism.

Back in October, an Atlanta Journal-Constitution story talked of the wonders of virtual colonoscopy, saying it replaced the dreaded colonoscope and lessened patient risk. It used these words to refer to the technology: "science fiction, Star Wars, video game, Disney World."

AJC virtual colonoscopy.png

Also in October, the Wall Street Journal promoted the growing popularity of virtual colonoscopies.

WSJ virtual colonoscopy.png

Neither story mentioned the fact that the U.S. Preventive Services Task Force had stated that same month that "The evidence is insufficient to assess the benefits and harms of computed tomographic colonography as a screening modality for colorectal cancer."

Last week's announcement that Medicare may stop paying for virtual colonoscopies also got little news attention. At least the New York Times reported it. Excerpts:

The Centers for Medicare and Medicaid Services said in a decision posted on its Web site that there was "insufficient evidence" to conclude that virtual colonoscopy "improves outcomes in Medicare beneficiaries."

...the United States Preventive Services Task Force, which advises the government on prevention, said last year that there was insufficient evidence to assess the benefits and harms of the CT technique. Some private insurers pay for the tests; others do not.
...
In its analysis, Medicare said many studies supporting virtual colonoscopy were done in people with a mean age around 58, so results might not fully apply to Medicare's older population.

For instance, older people are more likely to have polyps. So the proportion of people who would have to have a conventional colonoscopy after a virtual one would be greater. That would make the CT scan less cost-effective.

Surprise! PhRMA chief doesn't want Medicare negotiating drug prices

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I'll slip this in on the weekend because it's not really news and it's not at all surprising. PhRMA CEO Billy Tauzin is opposed to having the feds negotiate Medicare drug prices. The Medicare drug legislation he fought so hard to get passed while a Çongressman- even being singled out for praise by President Bush - bans such price negotiations. It closes the door on Medicare being able to wield its massive purchasing power in a way that could help health care consumers.

But that's not the way good old boy Billy sees it.

From the Kaiser Daily Health Policy Report last week:

Allowing Medicare to negotiate prescription drug prices on behalf of beneficiaries could reduce the number of drugs the program offers and result in higher costs for beneficiaries, Pharmaceutical Research and Manufacturers of America President and CEO Billy Tauzin said Wednesday, CQ HealthBeat reports. According to Tauzin, Medicare now offers access to thousands of drugs because the program relies on private-sector competition. Tauzin, speaking at a media roundtable, said, "When you put the government in the process you freeze out the private sector."

HHS Secretary-designate and former Senate Majority Leader Tom Daschle (D-S.D.) last week in testimony before the Senate Health, Education, Labor and Pensions Committee said the idea of allowing the secretary to negotiate drug prices "ought to be evaluated and looked at." Supporters of the idea have said it could save taxpayers billions of dollars and lower drug prices for all U.S. residents

It'll be fun to watch Billy function without his buddy in the White House.

By the way, if you never saw the 60 Minutes profile of Tauzin's role in the passage of the Medicare drug legislation, give it a look someday.

Big business in snoring and apnea

I've been waiting for someone to do a story on the amount of attention and money that's being spent on snoring and sleep apnea, and a USA Today story comes closest to what I've been waiting for.

The story explains that Medicare approved $571 million in payments for devices called continuous positive airway pressure (CPAP) machines last year, up from $291 million in 2004. The story explains that "Spending could grow even faster under a new federal rule that makes it easier for patients to get the devices by testing for sleep apnea at home rather than in a sleep testing lab."

The story raises some important questions:

Some experts warn there is a potential for unneeded prescriptions for CPAPs. "Are people getting treatment they don't need?" asks Fred Holt of the National Health Care Anti-Fraud Association, composed of health insurers and law enforcement groups.

"Not everyone with a diagnosis of sleep apnea needs CPAP," says Holt, an ear, nose and throat surgeon. "Weight loss, avoiding alcohol and sedatives at bedtime or changing sleep position could eliminate the problem for some."

For others, treatment involves sleeping with a mask connected to the CPAP machine, which blows air into the patient's nose, helping prevent obstruction to breathing.

Until this spring, Medicare would pay for CPAP machines only if a sleep center diagnosed patients with apnea. New rules say a diagnosis can be made with a test taken at home.

Opponents say home testing is less accurate. "To be adequately treated, you have to make sure patients are adequately diagnosed," says Mary Susan Esther, president of the American Academy of Sleep Medicine, a trade group representing sleep labs.

Proponents such as William Abraham, a sleep expert and chief of the division of cardiovascular medicine at Ohio State University, say the change makes it possible for more patients to get tested.

"By allowing home testing, perhaps Medicare is opening the floodgates," he says. Yet given the problems of untreated apnea, "it's not only the right thing to do, but may ultimately prove to be a cost savings."

Still, any time you hear about more testing, and with financial incentives to test and to treat, you should know that the risk for abuse, and for unnecessary testing, treatment and spending is high.

Bob Laszewski says "In the most amazing turn of events I have seen in 20 years of following health care policy in Washington, DC, the Democrats have the Republicans backed into an awful corner over the issue of the July 1st automatic 10.6% Medicare physician fee cut and corresponding private Medicare cuts to pay for nixing it. Also at stake is another 5% physician fee cut set for January 1, 2009."

Read his thoughtful blog piece.

Sometimes journalists are criticized for covering the "horse race" aspects of policy discussions. Sometimes, like this, it can't be avoided.

Medicare to pick up tab for more heart scans

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Earlier this week, Merrill Goozner may have given us the spot-on scary political reality when he put his touch on the story of Medicare approving new payments for expensive heart scans. Excerpt:

I suspect there will be a lot more of these decisions over the next nine months as Bush administration appointees hoping to line up their next jobs grant top-of-the-wish-list favors to special interests.

The New York Times website reported Wednesday that the Center for Medicare and Medicaid Services has reversed a proposed policy to cut off paying for heart scans, which can cost $600 or more. The preliminary decision announced last December found no clinical evidence that heart scans identify heart disease any better than other non-invasive procedures, like a stress test. According to the paper:

Medicare’s initial proposal, which would have ended payment for the scans unless the patients were enrolled in studies to determine the technology’s effectiveness, had met with fierce resistance from the doctors who perform these scans and the companies that make the equipment. They strongly defended the use of these scans as an important alternative to traditional angiography. ...

Lobbying by docs and equipment makers. Pay first, evidence later. It's the American way.

Call for transparency in Medicare's use of journals

U.S. Senator Charles Grassley (R-IA) has asked Medicare how it "assesses the content of the journals of science and medicine that it uses, in part, to make decisions about Medicare payments."

In a news release Grassley said, “I want to make sure the federal government relies on the best available science and that’s science that is peer-reviewed and free of bias."

In the letter to Medicare, he wrote: "Conflicts of interest have been proven in peer-reviewed studies to have a significant impact on scientific outcomes. Accordingly, it is important that scientific journals maintain policies of transparency and financial disclosure. ... With this issue in mind, it is troubling that few journals require authors to reveal who funded their research. Indeed, a 2001 study examined the top 1000 journals in science and medicine. The researchers found that only 16% of the journals had conflict of interest policies."

The Integrity in Science Watch program says that Medicare recently named 11 journals to the list of medical journals used to justify reimbursement for off-label use of cancer drugs. At least one of the journals did not require authors to disclose conflicts of interest and more than half did not require registration of clinical trials prior to publication, according to an Integrity in Science Watch survey."

Kickbacks to orthopedic surgeons

From Integrity in Science Watch, a publication of the Center for Science in the Public Interest:

"Nearly 50 orthopedic surgeons, many affiliated with the nation’s top teaching hospitals, each earned over $1 million a year in consulting contracts and royalties from the five companies that make artificial knees and hips. The payment disclosures were posted on the companies’ websites last week as part of a $311 million anti-kickback settlement between four of the firms and the U.S. attorney for northern New Jersey. The complaint had accused the companies of using consulting contracts as an illegal kickback scheme to get surgeons to use a particular company’s artificial joints. ...

With seniors accounting for nearly 70 percent of the knee and hip replacement market, Medicare spent $16 billion on the procedures last year. A typical knee replacement costs $33,000, according to Medicare records. A spokesman for Christopher J. Christie, the U.S. attorney in Newark, said the investigation into the alleged kickback scheme is ongoing."

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