Thursday, March 11, 2010

Are too many heart caths done?

Yes, so says a study from Duke. Around 6 in 10 patients getting a heart cath don't have any blockage. Now, the point of the heart cath is to figure out if you have blockage, but if 6 in 10 show no, the question is whether there is a less invasive (and less risky to patients) and cheaper way to figure out there is no blockage.

Lets think about how we might address this issue, focusing on Medicare for a second. The Senate bill includes an Independent Medicare Advisory Commission. This is the type of stuff on which they would focus. When should a cardiac cath be paid for by Medicare, and how should in be reimbursed. The current state of nature is that Medicare will pay for it if I doctor says you need it. And the doctor and the hospital will get paid more for doing this test than another less invasive test. So, the current system has incentive to over provide.

And the definition of over provide here is the study saying 6 in 10 tests showed no blockage. If there was never a test with no blockage, you would be under you are looking for the 'correct or appropriate' rate of provision, which is not so easy to figure out, even conceptually. Stick with me.

Medical malpractice. If the test is overdone, some of it could be driven by fear of getting sued. However, the evidence on the degree to which reforms of medical malpractice actually reduce the cost of health care is not so strong. Texas is typically held up as a poster child for malpractice reform. Doctors malpractice premiums have dropped, but not the cost of medical care. That is likely because of the fact that what gets termed over provision has multiple motivations, first and foremost, that doctors and hospitals get paid to do this. Changes in medical malpractice won't have as much effect on this as most think.

Change the way the providers are paid. In simplistic terms, if physicians are salaried, they have no incentive to over or under provide. However, even a physician who is salaried understands that the volume of procedures done influences the bottom line of their employer (say if employed by a community hospital) and therefore their salary. So, just moving toward something like salaried docs won't get rid of the incentive to over provide.

Change the cultural expectation that more is always better. Patient preferences and desires are very important in driving this. Presumably, choices are given to the patient in these situations whereby they can have a cath or they can do something less invasive. However, this study looked at folks with some chest pain and some abnormal stress testing. So, they are scared and/or in pain. The way the choice is provided will have a tremendous impact. This is about physician/patient communication and how people decide. So, we have a cultural preference for more, over laid with a situation in which a person is scared and vulnerable, so I suspect the people who get this are given a choice in which the physician says 'you should do it' and the ones who don't get it done are responding to a doc saying 'don't do it.' This will never change.

Market or expert rationing? The IMAC approach can be understood as expert driven rationing. Seeking to answer some of the questions raised by this study, when should test x be done, and then moving to either limit the use of a test/technology in given circumstances and/or altering the payment to lessen the incentive to over-provide (so called 'bundling' of care, or moving toward capitation based payments and away from fee for service).

This scares people, mainly because they assume more is always better. And this sounds like sometimes getting less. Yes. Because the test appears to be over used. And it is not risk free. Some will say, lets let the market fix it. That phrase makes great sense culturally to Americans, but what does it mean?

Paul Ryan's proposed fix for Medicare goes like this. If you are 54, when you turn 65 you will not be enrolled in Medicare. Instead, you will be given a voucher with which you can purchase private health insurance. Now, the voucher will be worth less than what Medicare per capita spending will be in that year for the persons still in Medicare. It will be set by taking the Medicare per capita expenditure next year and letting it rise between general inflation and actual health care inflation for a decade. This will do several things:
*reduce the federal government's costs for insuring elderly persons.
*shift more of the costs to individuals
*the two items above should slow the rate of health care inflation

How would this arrangement influence the cardiac cath story? I think in the following ways:
*probably reduce the volume of cardiac caths because people face more of the true cost of getting one, and presumably insurance will pay less for them.
*it is not clear whether unnecessary tests will be the ones most likely to be avoided. There are so many variables at work. How will private insurers alter payment for such tests? Will they set standards for when such tests can be ordered which will reduce the number of tests? Will insurance companies have to insure all comers? The voucher amount would differ by variables related to risk, but the details are murky.

The capping of the federal government's cost for insuring elderly folks is a blunt tool, and it is not clear how all the effects will work out. However, when you get down to the patient encounter level: chest pain, and an abnormal stress test, I guarantee you that fear and wanting reassurance from your doctor will be foremost in you mind and not 'shopping around.'

So, it seems clear that we overuse expensive technology. But, it is hard to do anything about it. There seem to be two choices out there. Expert driven physician rationing of care that provides guidance of when tests can and cannot be done, presumably with options that allow discretion. Or a voucher-based approach that fixes the federal government's costs and assumes the rest will work out. Both approaches have as their goal reducing expenditures over the level they will be with no intervention.

When the rubber meets the road, if we reduce the rate of doing this procedure, either Medicare or a private insurance company will have to intervene and place a constraint of the use of this procedure, or at least on their paying for it. The country has to figure out which one it prefers to be involved in this decision.

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