Tuesday, January 10, 2012

Good diagnosis, Zeke. Why no cure?

I really like it when I agree with Zeke Emanuel and never more so than with his recent column in the New York Times about proton beam machines.  You will recall that I addressed this topic several months ago.

He notes:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers. But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. 

And here's the upshot: 

With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy. 

If the United States is ever going to control our health care costs, we have to demand better evidence of effectiveness, and stop handing out taxpayer dollars with no questions asked. 

So why doesn't the administration, which runs and controls Medicare, change this?  Didn't you work in the White House, Zeke?  Can you tell us why?

9 comments:

Barry Carol said...

As I understand it, under current law, Medicare is specifically precluded from taking cost into account in determining what services, tests, procedures and drugs to pay for or not pay for. If it’s approved by the FDA, Medicare usually pays for it. That needs to change, though those opposed to cost-effective care will shout about rationing and death panels. If it were up to me, the solution to the use of proton beam therapy for prostate cancer wouldn’t need to be refusing to pay for it. Reference pricing would probably be sufficient. That is, pay only as much as the reimbursement rate for less expensive but equally effective treatment.

Anonymous said...

Barry, you are correct - but I believe the new health care law provides for an independent board to make recommendations to Medicare on what to pay for. If Congress does not act to change these recommendations within a specific period of time, they become automatic. The idea was to remove Congress from the political fallout caused by restrictions.

That is, if my facts are correct. Anyone else remember it this way?

nonlocal

Anonymous said...

Sorry; I should have researched my comment first rather than last, but here it is, the new board:
http://en.wikipedia.org/wiki/Independent_Payment_Advisory_Board

nonlocal

Anonymous said...

Proton beam radiation offers less side effects than conventional radiation. That was a major issue for my husband and me. When you start reading about side effects from prostate surgery, and from conventional radiation, fewer side effects are a very real consideration.
Getting proton beam radiation, which is available in far fewer places than conventional radiation treatment, can involve additional costs to many patients. Many patients can't afford to get this treatment, either because of job considerations, or money issues, or both. My husband and I were fortunate. We were able to travel to, and stay in, a rental in Loma Linda, California, for over two months so his prostate cancer could be treated with proton beam radiation. We have no regrets.
There we met patients from all over the country who had made the same cost/benefit decision as we did.
We also met patients not there for prostate cancer treatment. We met, for example, a young Canadian woman who had brain cancer, and had decided on proton beam therapy, which was not available to her at home.
And we met a couple who were there because his surgery had generated good PSA results for 8 years--and then the cancer made a comeback.

Barry Carol said...

nonlocal –

I remember it the same way you do. However, the IPAB is not scheduled to begin operation until 2015, I believe, if Congress doesn’t kill it before then even if most of the rest of the ACA survives. There are also significant limitations on what it can and can’t do. For example, it can’t increase beneficiary cost sharing, eliminate benefits or change the beneficiary’s relationship with Medicare in any way. About all it can do is to squeeze provider payments and perhaps try to introduce new payment models. My suggestion of reference pricing for proton beam therapy may or may not pass muster. I’m not sure.

Personally, I’m more optimistic about new physician guidelines that direct them to incorporate the wise stewardship of society’s limited resources into their practice patterns. Also, a well conceived premium support approach to Medicare financing could also, over time, lead to more efficient resource use and allocation.

Anonymous said...

Barry, how do you see this premium support thing working? I could see it being immediately overwhelmed by continually rising costs.

nonlocal

David said...

Wanna bet the reason it doesn't come under fire is they don't want to be accused of destroying jobs?

GB said...

The editorial suggests "Of course hospitals could continue charging patients more for proton beam therapy, and patients who wanted the treatment could pay the difference themselves." Is that legal under current Medicare regulations? I don't think so. That would solve a lot of dilemmas we face today with implants and other implanted devices too. I am under the impression a Medicare patient would need to deny their medicare coverage completely

Barry Carol said...

nonlocal –

I’m not sure how well premium support would work for Medicare. It would be more challenging to cover the Medicare population this way than the 18-64 year olds. It also would probably not be a good idea to index the premium support amount to the Consumer Price Index or GDP growth. A metric that incorporates medical cost growth would be better. It would be helpful to force people to pay out of pocket for the difference between the basic plan and a plan with more comprehensive coverage and/or a broader provider network. The Brookings Institution recently published a primer on the premium support model but, unfortunately, I don’t have the link. I also note that Medicare Part D which has no public option has worked far better than early critics expected and the cost is something like 40% below initial estimates. Perhaps that model could be expanded to the rest of Medicare which should probably combine Parts A and B into a single plan with a higher deductible, appropriate co-insurance and a reasonable out-of-pocket maximum limit.