Re: Seven Ways to Reduce Unnecessary Medical Costs --Right Now

Allan wrote:
On Sep 12, 7:15 pm, Islander <nos...@xxxxxxxxxxx> wrote:
Gary wrote:
Seven Ways to Reduce Unnecessary
Medical Costs --Right Now!
George D. Lundberg, M.D.
I believe that there are still many ethical and professional American
physicians and many intelligent American patients who are capable of,
in an alliance of patients and physicians, doing "the right things."
Their combined clout is being underestimated in the current healthcare
reform debate.
Efforts to control American medical costs date from at least 1932.
With few exceptions, they have failed. Health care reform, 2009
politics-style, is again in trouble over cost control. It would be
such a shame if we once again fail to cover the uninsured because of
hang-ups over costs.
Physician decisions drive the majority of expenditures in the US
health care system. American health care costs will never be
controlled until most physicians are no longer paid fees for specific
services. The lure of economic incentives to provide care that is
unnecessary, unproven, or even known to be ineffective drives many
physicians to make the lucrative choice. Hospitals and especially
academic medical centers are also motivated to profit from many
expensive procedures. Alternative payment forms used in integrated
multispecialty delivery systems such as those at Geisinger, Mayo, and
Kaiser Permanente are far more efficient and effective.
Fee-for-service incentives are a key reason why at least 30% of the
$2.5 trillion expended annually for American health care is
unnecessary. Eliminating that waste could save $750 billion annually
with no harm to patient outcomes.
Currently several House and Senate bills include various proposals to
lower costs. But they are tepid at best, in danger of being bought out
by special interests at worst.
So, what can we in the USA do RIGHT NOW to begin to cut health care
costs?
An alliance of informed patients and physicians can widely apply
recently learned comparative effectiveness science to big ticket
items, saving vast sums while improving quality of care.
1. Intensive medical therapy should be substituted for coronary
artery bypass grafting (currently around 500,000 procedures annually)
for many patients with established coronary artery disease, saving
many billions of dollars annually.
2. The same for invasive angioplasty and stenting (currently around
1,000,000 procedures per year) saving tens of billions of dollars
annually.
3. Non-indicated PSA screening for prostate cancer should be
stopped. Radical surgery as the usual treatment for most prostate
cancers should cease since it causes more harm than good. Billions
saved here.
4. Screening mammography in women under 50 who have no clinical
indication should be stopped and for those over 50 sharply curtailed,
since it now seems to lead to at least as much harm as good. More
billions saved.
5. CAT scans and MRIs are impressive art forms and can be useful
clinically. However, their use is unnecessary much of the time to
guide correct therapeutic decisions. Such expensive diagnostic tests
should not be paid for on a case-by-case basis but grouped along with
other diagnostic tests, by some capitated or packaged method that is
use-neutral. More billions saved.
6. We must stop paying huge sums to clinical oncologists and their
institutions for administering chemotherapeutic false hope, along with
real suffering from adverse effects, to patients with widespread
metastatic cancer. More billions saved.
7. Death, which comes to us all, should be as dignified and free
from pain and suffering as possible. We should stop paying physicians
and institutions to prolong dying with false hope, bravado, and
intensive therapy that only adds to their profit margin. Such behavior
is almost unthinkable and yet is commonplace. More billions saved.
Why might many physicians, their patients, and their institutions
suddenly now change these established behaviors? Patriotism,
recognition of new science, stewardship, and the economic survival of
the America we love. No legislation is necessary to effect these huge
savings. Physicians, patients, and their institutions need only take a
good hard look in the mirror and then follow the medical science that
most benefits patients and the public health at lowest cost. Academic
medical centers should take the lead, rather than continuing to teach
new doctors to "take the money and run."
Physicians can reaffirm their professionalism with sound ethical
behavior and without undue concern for meeting revenue needs. The
interests of the patients and the public must again supersede the
self-interest of the learned professional.
Dr. Lundberg, a former Editor in Chief of Medscape, eMedicine, and the
Journal of the American Medical Association, is now now president and
board chair of The Lundberg Institute.
This article was posted on August 13, 2009.
http://www.insurancereformwatch.org/proposals/lundberg.shtml
Comparative Effectiveness is a very good idea, but the mere mention of
it in H.R. 3200 caused the political right to scream "rationing!"

Why can't the administration stand up and say that YES it will result
in rationing and this is a GOOD and NECESSARY thing.

Because it has nothing to do with rationality. It is politics. The political right would have a field day!

Contrary to what the author of this piece implies, comparative
effectiveness is the study of alternative treatments so that the best
treatments can be selected. That is far more than (but may include)
discontinuing treatments that are not effective.

The problem with comparative effectiveness is the challenge of
actually collecting the data. The second challenge is that CE is that
it must be, by design, population based. It is not a determinant of
the best clinical practice at the patient level - it can't be and it
shouldn't even be attempted. Finally and most importantly, in the
absence of an economic criterion (ie cost effectiveness) Comparative
Effectiveness is pointless.

I think that you have a blind spot on this. From a business point of view, cost is the metric of choice, but from a broader point of view, cost is only one of several metrics, necessary, but not sufficient.

One of the examples cited in Gary's 10 is about technology - CAT and
MRI. MRI's are much better (more effective) in detecting small tumors
than traditional x-rays. CAT scanners are much better in evaluating
soft tissue injuries (sports injuries as an example) than x-rays. But
the argument is made that it is "wasteful" - and as such Comparative
Effectiveness data would suggest to use them and cost-effectiveness
likely would tell you not. I have plenty of other examples if you
like.

Here is a remarkably frank commentary from a conservative friend from Texas:
"Texas has a culture where clinics in small towns are owned by the doctor’s. They are god awful in the management of their clinics, so they simply charge more to offset their inefficiency. They also tend to egomania, and are gadget freaks, so they purchase as many CAT scanners or MRIs as possible, and offset the charges by using the devices as often as possible. They also own or organize the nurse’s aid groups, have a piece of the pharmacy, and can write off for the iRS everything but the kitchen sink to the clinic."

I am guessing that Comparative Effectiveness analysis will not change that.

Frankly, I'm surprised that the insurance industry is not supporting
comparative effectiveness. Perhaps they have simply lost control of
their mobs.

The insurance industry - more specifically the medical managed care
industry - does use comparative effectiveness - moreover, they use
cost-effectiveness - you need to read the AMCP guidelines on dossier
submissions for pharmaceuticals if you would like an example. CMS has
done very little of this for Medicare. Not since OTA have they done
systematic reviews.

As you may have recognized, I probably know more about this stuff than
most. There's a reason for this.

allan.

Yes, you work in the field. It does raise an interesting question, however. How is the average person supposed to deal with a system this complex? It is clear to me that we cannot trust the health insurance industry. While you have a lot of experience and can speak knowledgeably on the topic, you, like everyone, have a bias. It is not at all clear to me at this point that Congress is acting with any more knowledge of the field than the average citizen. Who is the knowledgeable, yet impartial advocate for the public?
.

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