Stakeholders, Wonks, and The Setting of Limits
It would be wonderful if we could contain medical costs by selectively eliminating care that yields no clinical benefits. That's what Washington's health reformers keep promising. Withholding care that saves lives in order to save money is as unspeakable in Congress as it is at the bedside. And yes, there's some truth to what I was asked to say as an Obama surrogate about opportunities to slash medical spending that buys us nothing. There's the 30 percent of health spending that's wasted on worthless care1—about the price of the $700 billion mortgage bailout, squandered each year. Plus there's the 10 percent or so of medical spending that covers avoidable administrative costs — another $200 billion a year. It surely makes sense to target this spending, by learning more about which tests and treatments work, cutting out those that don't, and getting rid of pointless bureaucracy.
But cutting out the care that's useless is astonishingly difficult. Most people think that doctors know which tests and treatments do and don't work — for most patients, at least. So did I, until it dawned on me a few months into medical school that my pediatrician had put one over on me by telling me he knew his nostrums would help. I'd fled, as an eight-year-old, from his allergy shots — under the examining table, up some stairs, and into a closet out of his reach. And, it turns out, the sorcerer's mix of mold, pollen, and mammal hairs he injected into me weekly, when he could catch me, hasn't been shown to work, notwithstanding the hundreds of dollars my parents spent on the stuff. My medical professors challenged me and my fellow first-years to insist on proof — and showed us that many of the treatments
in common use do nothing. The same year, the Office of Technology Assessment (an agency that advised Congress on scientific questions until it was shut down in 1995) estimated that only about 10 to 20 percent of medical procedures rest on "gold-standard" evidence — randomized clinical trials.
It's doubtful that this percentage has changed much in the thirty years since. The challenges are daunting. Drug companies, makers of medical devices, and clinical specialty societies fiercely resist efforts to compare tests and treatments and to condition payment on proof of effectiveness. There are classic horror stories, including that of the back surgeons who arched their backs when a federal agency empowered to make science-based treatment recommendations concluded that evidence favored fewer spinal operations for lower-back pain. Facing down this threat, they convinced Congress to geld the agency by barring it from issuing clinical guidance.
A more recent example is so-called "CT angiography," which sums up serial, CT slices of the heart to create stunning three-dimensional views of clogged (or clear) coronary arteries. These images allow a glimpse inside the heart without so much as a needle stick. But whether this look enables doctors to save lives is uncertain. Their use soared in 2006, after General Electric brought high-resolution, 64-slice scanners to market. Medicare officials became alarmed about the cost. In December 2007, the agency that runs Medicare said it would pay for the scans only in limited circumstances and only if the doctors who did them participated in studies of their effectiveness. Physicians who'd invested in the machines went to war, demanding that Medicare cover the scans without condition. They lobbied Congress (as did GE), getting 79 Members to sign onto a letter asking the agency to pay for them without limitation. Three months after its December announcement, Medicare reversed course, saying it would cover the test without restrictions and offering only "hope" for future studies of the scans' effectiveness.
Risky and pricey therapies routinely make their way into common use without such studies. Recent examples include hormone replacement for post-menopausal women and use of tiny screens coated with anti-clotting drugs to prop open coronary arteries; both treatments made headlines when federally funded clinical trials found that they killed more people than they saved. Another federally funded study, also conducted after-the-fact, revealed that a whole family of new, patent-protected antipsychotic drugs, adopted by most psychiatrists in the 1990s in response to aggressive marketing, performed no better than cheap, generic medications.
What was most remarkable about these episodes was that rigorous studies were eventually done. The CT angiography story is more typical: new technologies stream into the market with minimal attention to their comparative efficacy. Private insurers won't pay for such studies for reasons that are right out of Economics 101: a finding that a therapy is ineffective benefits all insurers, not just the firm that funded it. Comparative effectiveness research is, in economics lingo, a "public good" — its results are available to all (through publication) and so can't be used by one health plan to get a leg up on its rivals.
Change is looming. The 2010 health reform law created a "Patient- Centered Outcomes Research Institute," funded by levies on Medicare and private insurers, to sponsor such research. But the funding level, less than a tenth of a percent of what Americans spend on health care each year, will do little to increase the fraction of medical decisions that rest on science. And the Institute's governing body — composed mostly of representatives from the hospital, insurance, and drug and device industries, as well as physicians — seems almost designed to enable stakeholders to block studies that threaten their interests. Moreover, multiple provisions in the law (sought by providers and drug and device makers) hobble Medicare's ability to base coverage decisions on research the Institute sponsors.
Excerpted from The Hippocratic Myth: Why Doctors are Under Pressure to Ration Care, Practice Politics and Compromise their Promise to Heal by M. Gregg Bloche M.D. Copyright 2011 by M. Gregg Bloche M.D. Excerpted by permission of Palgrave Macmillan. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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