Over at Healthcare ZDNet, a site new to me, Dana Blankenhorn says
The Obama strategy for achieving health reform is now clear.
Get the money first. This changes the terms of the debate, from what will it cost to how do we do things more efficiently?
He's got a point, but it seems to me he's only half right -- or a bit less -- for the push to establish comparative effectiveness data based on (the establishment of) electronic health records also does much to answer how to do things efficiently. That data will help identify where expensive procedures and drugs bring benefit and where they don't; and it'll also reveal which drugs and devices work better than others, so doctors can try the most effective ones first.
It will also probably -- well, certainly -- mean curtailing use of many procedures that simply don't bring benefit in certain circumstances, as noted in a Times editorical last week on "Evidence and Health Care Reform."
Medicare has proposed not to pay for so-called virtual colonoscopies because there is not enough evidence that they would benefit people aged 65 and older. That may be disappointing for older Americans who would prefer a virtual exam to a real one. But those sort of judgments will be fundamental to any successful health care reform effort. Eliminating unproven procedures and reducing needless costs is necessary if the nation is to improve the quality and lower the cost of care over all.
We'll see a lot of this, especially in imaging, which works wonderfully -- but not nearly as wonderfully as we like to think. As a recent story at CNN notes,
President Barack Obama's budget proposal aims to save $260 million over 10 years through the use of so-called radiology benefit managers to "ensure that Medicare makes appropriate payments." The services of such companies, including Magellan Health Services Inc. (MGLN), are already commonly employed by outside insurers to pre-screen pricey requests for using high-end tools such as MRI and CT scanners.
Some sort of filter on such use is needed, and it needs to be based on large pools of data of the sort electronic health records (EHRs) can provide.
But these proposals to reduce unnecessary diagnostic procedures and treatments are going to bring the "rationing" complaint, which promises to be a rallying cry for the industries who will oppose such evidence-based guidelines. From the CNN story:
But a strongly worded release from an association representing imaging companies, including units of General Electric Co. (GE) and Siemens AG (SI), said pre-screening could hurt patients.
The budget's reliance on radiology benefit managers, or RBMs, "will deny imaging services, and is an ineffective model that undermines the doctor-patient relationship in making health care decisions," said the Medical Imaging & Technology Alliance, which represents dozens of imaging companies.
The group supported the health-policy goals in Obama's $3.6 trillion proposal, but said using RBMs "will lead to further reducing seniors' access to life- saving medical services."
I'm not clear at this point on how Obama figures to monitor and filter such uses. Insurance companies already use companies, like the Magellan outfit noted above, to make some of these calls, so there's a certain logic in using them for Obama's plan. On the other hand, those outfits aren't exactly popular favorites. If Obama's going to make this work, he has to find a way to sell the idea of systematically curbing the use of procedures that have been successfully sold as state-of-the-art -- but which bring benefit in some circumstances and not others. As noted in this Reuters story, Obama's budget director, Peter Orszag, estimates such unnecessary procedures cost us as much as $700 billion a year. (That story also gives a useful broader look at how the Obama's plan relies heavily on evidence.)
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