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A Modest Proposal: Pay More for Care Only if It's Better

Cheryl Clark, for HealthLeaders Media, October 7, 2010

Insufficient Evidence:  If there's no evidence the service is superior, comparable or inferior, payment would be set on a cost-plus basis for three years, after which CMS would reevaluate.  After three years, if evidence remained insufficient or demonstrated no advantage, payment would be lowered.

If that evidence showed the service was actually inferior to prevailing standards of care, "Medicare could reevaluate whether the service was reasonable and necessary." If evidence showed comparability or superiority, payment would go up.

"The majority of services covered under Medicare have historically fallen into this (insufficient) category because the evidence has been insufficient to determine their comparative clinical effectiveness," Pearson and Bach wrote.

In my interview with Bach, he pointed to the variety "of cardiac defibrillators with different price points that have never been compared. There are implants like that as well. And the truth is that cancer drugs come on the market that have never been compared to the cheaper alternatives."

A case in point is expensive intensity-modulated radiation therapy developed in the last decade.

Clinicians presumed it was better than the old way because it focuses radiation just on the tumor cells rather than surrounding tissue. But there have been no randomized trials showing better tumor cell eradication or reduced toxicity, the authors say.

Yet that's not reflected in the price Medicare pays. "For prostate cancer—the most common form of cancer for which this new therapy was used—reimbursement to providers for a single course of treatment was set at approximately $42,000," he and Pearson wrote. With the old way alternative, three-dimensional therapy, Medicare paid only $10,000.

"This discrepancy led providers around the country to buy intensity-modulated radiation therapy machines and to abandon conventional three-dimensional therapy," he and Pearson wrote. That made it difficult to recruit clinicians or patients for clinical trials to compare the two, and the added cost to Medicare's prostate cancer treatment bill topped $1.5 billion.

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1 comments on "A Modest Proposal: Pay More for Care Only if It's Better"


Susan Collingwood (10/21/2010 at 3:01 PM)
This proposal sounds like a fantastic way to gut medical innovation. True, evaluation of care results needs to be done. HOWEVER, the Randomized Clinical Trial model has *significant* flaws. In the cancer example cited, it often takes 10 YEARS or more to get meaningful data on "ultimate outcomes". Further, the proposal basically suggests physicians request patients to voluntarily subject themselves, for example, to *ADDITIONAL RADIATION* (that we already know is bad for them[INVALID]that's why we strive to limit it!) on the *off chance* that the additional radiation we know the patient will receive in conventional radiation therapy is not that harmful, despite the known improvement in reduced tissue irradiation in IMRT, and huge improvement in proton beam. This does not, of course, even take into account the reasonable expectation that the IRMT or proton beam therapy may actually have a better outcome in curing the cancer! Further, in evaluating the treatment, the author's proposal suggests that *without* a RCT, one is free to ignore other evidence (like physics involved), since it's not a RCT with a defined endpoint. Because newer care is often more (or even much more) expensive than existing care (due to additional costs of technological innovation, or even needed physician time [see the comparison in Dr. Gawande's book, "Better", between the care delivered by the CF programs[INVALID]and note the mortality experienced), the threat of not having reimbursement until a RCT (in the case of the cancer sited, of at least 10 years) is completed is VERY likely to entirely stifle medical innovation.