Health care costs continue to spiral. We have too much unnecessary testing and care. The Wall Street Journal had a wonderful article yesterday that dissected the impact of the COURAGE trial. For those who do not remember:
The study, known as "Courage" and published in the New England Journal of Medicine in 2007, shook the world of cardiology. It found that the most common heart surgery—a $15,000 procedure that unclogs arteries using a small scaffold or stent—usually yields no additional benefit when used with a cocktail of generic drugs in patients suffering from chronic chest pain.
The Courage trial was led by William Boden, a Buffalo, N.Y., cardiologist, and funded largely by the Department of Veterans Affairs. It tracked 2,287 patients for five years and found that trying drugs first, and adding stents only if chest pain persisted, didn't affect the rate of deaths and heart attacks, although stents did produce quicker pain relief.
As the Journal reports, the first year after the trial's publication stent rates decreased significantly. But now we have more stents. They explain:
For a brief while, they were right. U.S. stent implants declined 13% in the month after the study's release. But as the headlines about Courage faded, stentings soon began to rise again, and are now back at peak levels of about one million a year, according to hospital surveyor Millennium Research Group.
"Most [cardiologists] haven't voluntarily incorporated the Courage criteria into their practice," says Dr. Boden. "What's going to continue to drive practice is reimbursement."
Now for the cardiologists reading this rant, you are not evil. Even the interventional cardiologists are only trying to provide the best care for their patients. Remember Abraham Maslow's caution – "If you only have a hammer, you tend to see every problem as a nail."
What internist or family physician believes that oncologists never get too aggressive with their infusions? Why do they make patients sick with their concoctions that have almost no chance of working?
Why do radiologists often suggest another more expensive study? Why do orthopedic surgeons operate on backs when the data the suggest much more stringent criteria?
Now I have only picked on a few subspecialties because I am tired of providing examples. You provide your own examples.
In all these examples, the physician making the "treatment" decision makes money from that decision. Money influences how physicians make decision, but likely implicitly. I would not be surprised if a subspecialist attacks this rant with an elegant explanation of their decision making. But when money does not matter – at the VA Hospital – I see very different decision making from the same subspecialties. When they are no longer paid by the procedure or encounter, they become much more conservative in their recommendations.
Our payment system encourages aggressive use of technology, because some physician is making money. I do not believe we can control health care costs until we change the monetary incentive system.
When interventional cardiologists make decisions about stenting, we have the equivalent of foxes guarding the hen house. The cardiologists truly mean well, and care deeply about their patients. But, I believe they do too much stenting and too little referring to CV surgeons for CABG. They will argue vehemently. I believe them honorable, but wrong.
Our payment system is unintentionally designed to encourage more care, even when more care is not better care. We must develop an entirely different payment system. Minor tweaks will not fix the problem.
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Today I got a denial letter from a prescription management company for zofran, a medicine they take fro chronic intractable nausea. the only medicine that works for them. Why was it denied? Because the FDA has not approved this medication for intractable nause. It is onlyFDA approved for chemotherapy related nausea, post operative nausea or radiation induced nausea.
Now I have to ask the question. When will the day come where heart caths and stents are denied payment because they didn’t meet the “FDA indication” or guidelines for evidence based guidelines.
When will that day come? I don’t know, but I’m glad I practice inpatient medicine where my decisions are based on what I think is best for the patient in the most cost effective way I know how. It would be even better if my cost effective quality was rewarded on a cost sharing basis with hospital reimbursement.
The best way to make medical care evidence driven is to bundle it. If cardiologists were paid a fee to provide the right evidence based care and not the care that gives them the best reimbursement, I’m sure a lot of the lucrative non evidence based practices would disappear overnight.
Instead I have a pharmacy denying zofran for a patient for which it is clearly the only option.
DB,
I agree with your general point but the WSJ article is distorted and not very informative abou stent utilization. see related post on my blog:
http://doctorrw.blogspot.com/2010/02/almost-three-years-after-courage-and.html
I guess it is still vogue to demonize private practice enterprise these days. We can thank Dr. Gawande for that. This kind of thinking will lead us down the road toward socialized medicine. The last tiime I checked, physicians weren’t lining up to go work at the VA. I wonder why?
Payment systems are either primarily market based or politically based. Our present system is politically based and the most political power flows to those who are able to harvest the best payment from the political system. Through this mechanism, the payments and power distributions tend to be self perpetuating. The outcomes data is never going to be unambiguous enough to fundamentally change payments since this would result in basic shifts in political power.
There was a commentary piece in the NEJM which I recently blogged about – http://georgiacontrarian.blogspot.com/2010/02/politics-and-medicine.html
It is not only money driven, it is also litigation driven. For every VA study that shows no benefit, there will be an expert witness proving that the stent could have saved the patient’s life. Until you fix that, things won’t change.
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