Is Newer Better? Not Always

[okarol]

Editorial
Is Newer Better? Not Always
Published: September 11, 2010

The Congressional Budget Office estimates that an astonishing half or more of the increased spending for health care in recent decades is due to technological, surgical and clinical advances.

For the most part, such advances are a cause for celebration. But an expensive new drug is not always better than an older, cheaper drug, and sometimes a new technology or treatment that is highly effective for some patients is unnecessary or even dangerous for others.

The system almost seems designed to keep driving up costs.

To win approval, drugs and many devices must undergo tests for safety and effectiveness. For drugs, there is usually no comparison to products already approved. For both, there is no consideration of cost. Once drugs or devices are approved to treat one class of patients or illnesses, doctors can use them for virtually any ailment they please. Manufacturers eagerly promote their most expensive products to doctors and patients.

Patients have few ways to judge what is best for improving health or saving money. They must rely on doctors who may have insufficient information — or economic incentives to pick the costliest treatment.

The new health care reform law makes a start at figuring this out. It sets up a new system to evaluate the comparative effectiveness of drugs, treatments and medical devices. But, after all of the cynical demagoguing about “death panels,” it limits the extent to which the studies can be used to help hold down costs.

No one wants to bar patients from getting the treatment they need. But without curtailing the use of unnecessary, overly costly and even dangerous new technologies and surgical procedures, there is little hope of restraining the relentless rise in health care costs.

That is a truth that American politicians and taxpayers cannot afford to ignore for much longer.

The good news on medical advancements is undeniable. Doctors can now keep patients alive with improved dialysis treatments while they await a kidney transplant, replace disintegrating hips and knees with artificial joints, and spot internal growths with high-tech imaging devices that avoid the need for exploratory surgery.

Even costly therapies can end up saving money as well as lives. Studies by respected economists have shown that spending on new cardiac treatments, neonatal care for low-birth-weight infants, and mental health drugs have more than paid for themselves.

This is not always the case. Consider the prostate-specific antigen test, which is widely used to screen men for possible prostate cancer. In an Op-Ed piece in The Times in March, Richard J. Ablin, the doctor who discovered prostate-specific antigen, described the test as “hardly more effective than a coin toss” at distinguishing who is at risk, and lamented that the test’s popularity has led to “a hugely expensive public health disaster.”

Each year some 30 million American men undergo the test at a cost of at least $3 billion, and many go on to have surgery, intensive radiation or other damaging treatments that may not have been necessary.

Or consider complex fusion surgery to relieve lower back pain. An article and an editorial in the April 7 issue of The Journal of the American Medical Association deplored the rapidly rising use of this surgery, which fuses multiple disks in the spine, in patients who would have done better, and faced fewer risks, with simpler surgery that eases pressure on the nerves without fusion.

The explanation for the boom was likely economic. Surgeons were paid 10 times as much for the complex surgery, hospitals were paid three and a half times as much, and manufacturers reaped a bonanza selling $50,000 worth of implants for the complex surgery, compared with little or no profit from the simpler surgery.

Research that systematically compares the effectiveness of different treatments and drugs is clearly needed.

The Obama administration started the process, committing $1.1 billion from stimulus funds to finance comparative studies. The new reform law will move that ahead, setting up a nonprofit, independent institute to organize the work. The comptroller general will appoint a governing board of 19 members, representing patients, doctors, manufacturers and others, including two designated federal health officials.

If the institute works the way it is supposed to, patients, doctors and the government will have better information about what works and what does not, what may be worth the extra cost and what does not make sense. Even then, the legislative language is so convoluted there is no guarantee that even the most credible findings will help ensure that patients get the best and most cost-effective treatment.

With critics wrongly charging that these studies would insert government bureaucrats between patients and their doctors and end up denying access to essential care, reformers pulled their punches.

The institute is supposed to make regular reports of its findings but is carefully restricted as to what it can say. It cannot make recommendations to Medicare or private insurers about what they should or should not cover. It cannot tell doctors what treatments to use, or recommend how much doctors and hospitals should be paid for any services.

Depending on how the White House decides to proceed, the effort could begin to change things. The law says the secretary of health and human services cannot deny Medicare coverage of services “solely” on the basis of comparative effectiveness research, but it does not prevent the use of such findings in conjunction with other factors in making coverage decisions. Those decisions generally influence what private insurers cover as well.

The secretary needs to press the panel to get the research going and then begin including the findings in Medicare coverage and reimbursement decisions. Critics will howl. If the panel does its job right — and politicians have the courage to make the case — both patients and taxpayers will benefit.

http://www.nytimes.com/2010/09/12/opinion/12sun1.html?_r=1&scp=8&sq=dialysis&st=cse