Paying for things that work

I’ve received a number of emails about Ezekiel Emanuel’s and Steven Pearson’s op-ed in the NYT on Monday. I admit, part of the reason I haven addressed it is because I’m a little annoyed that so many of you thought this was a new idea. How many times have we written here about paying for things that work and not paying for things that don’t?

But I guess it isn’t “real” if it isn’t published in the NYT. (That was sarcasm).

Now to their argument. Here’s the setup:

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls. As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.

For a few pediatric brain cancers, this type of therapy seems to be better than what we would otherwise do. Fantastic. The problem is that the centers, in order to make the machines profitable, have started to used them on cancers where there is no evidence that they do a better job. Should insurance have to pay for that extra cost? Should Medicare?

We could say no, but then we won’t ever know if the things work. We could say yes, but only for studies. I’m more inclined to get behind that, especially if we agree that if the studies re negative, we stop paying. Or, we could go with the plan that I’ve been advocating for some time:

The most promising option is a new approach called dynamic pricing. Medicare would pay more for proton beam therapy, but only for diseases that are proven to be treated more effectively by the therapy than by other forms of radiation. For cancers like prostate, it would pay only what it pays for the cheaper alternatives. But if studies were done showing that proton beam therapy was better than other treatments, the payment would go up. If no studies were done, or the new evidence demonstrated no advantages, then coverage would continue, but at the lower reimbursement.

Of course hospitals could continue charging patients more for proton beam therapy, and patients who wanted the treatment could pay the difference themselves. But this should not be seen as unfair to those who can’t afford it, because there are alternatives that are just as effective.

I have absolutely no problem with people paying for stuff they want. This is the United States of America, and you should be free to pay for things with your own money. But I also have no problem saying that we shouldn’t use taxpayer money to pay for things that are more expensive, yet no better. I think I’ve been pretty consistent in saying that.

My problem with op-eds like this, though, is that they always focus on new, rare things. Oh, the outrage of proton beam therapy! It’s $50,000 per patient (versus $25,000 for non-proton beam therapy).

So, yes, this makes for a great piece in the NYT. But it ignores the millions of smaller things we do every day on a much larger scale that don’t work. The half-million arthroscopic knee surgeries to correct osteoarthritis of the knee, at a cost of $3 billion. The hundreds of billions of dollars we spend on drugs that are absolutely no better than other, cheaper ones. The MRI tests we order and the procedures we do that likely aren’t necessary. The mammograms, PSA tests, and PAP smears that can’t even be discussed without outrage and death panels being brought into play.

It’s a cultural problem as much as a medical one. It won’t be fixed by focusing on a rare treatment for a fatal disease. That makes for a great op-ed, but it’s not going to change the way we do things.

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