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Tuesday, January 3, 2012

How to Make Medicare Go Broke

Zeke Emanuel and Steve Pearson, colleagues I admire greatly, have an Op Ed in today's New York Times that shows how our current way of running Medicare will ultimately send the program down the tubes.

Here's the first paragraph, and the gist, of their argument:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.
Proton beam is a form of radiation that uses atomic nuclei rather than other sources of energy, such as gamma rays, x-rays, or electrons. Proton beams have less scatter, theoretically making it possible to provide more narrowly focused treatment, which, again theoretically, could allow more vigorous treatment of a cancer with less injury to surrounding tissues.

The key word is "theoretically." Proton beam fulfills its promise for relatively rare radiosensitive cancers in children and some rare nervous system tumors in adults. But for its widest use - prostate cancer - there is no evidence for superior outcomes. Medicare payment policy, however, results in a fee of about $50,000, twice as much as equally effective forms of radiation.

Facilities like Loma Linda in California, M.D. Anderson in Texas, Massachusetts General Hospital, University of Pennsylvania, and now two Mayo Clinic sites, are eager to pilot new forms of treatment and to maintain their competitive position in U.S. health care. You can get a sense of how actively marketed proton beam is from the Loma Linda website.

Zeke and Steve identify three alternative Medicare payment policies:
  1. Refuse to pay for proton beam except for  diseases where there is solid evidence for clinical superiority. This is what most private insurers do - as an example, see Aetna's detailed policy.
  2. Use the option of providing "coverage with evidence development," an approach whereby Medicare would cover proton beam for prostate and other cancers, but only for patients enrolled in a randomized trial comparing the treatment to its alternatives.
  3. "Dynamic pricing" - a system whereby Medicare would pay more for proton beam, but only for diseases for which the treatment has been shown to be more effective than the alternatives.
We seniors need to demand that Medicare follow the policies Zeke and Steve argue for. Doing so will (a) protect us from economically-driven recommendations for treatments we don't need, and (b) help to constrain Medicare costs so that (c) future generations can have the same advantages we have. What they propose isn't rationing - it's prudent spending for demonstrated value. That's something we do in our own lives all the time!

[Zeke and Steve's analysis sets in after treatment for prostate cancer has been recommended. Alas, there's lots of reason to believe that many men are treated for cancers that would not have impaired their health or longevity. Overuse of the PSA test is another story for another time, but if you're interested, there's an excellent NPR interview  with Dr. Gilbert Welch, author of Overdiagnosed: Making People Sick in Pursuit of Health.]

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