A transparent process to allocate resources based on evidence

The New York Times reports on Washington state’s efforts to “to determine which medical devices and procedures Washington will cover for state employees, Medicaid patients and injured workers, about 750,000 people in all.”

An expert panel, appointed by the state, is getting national attention, writes the Times, “in part because its process is public and open. . . [and] provides a living laboratory of the complexities of applying evidence-based medicine, something that is becoming more common as a way to rein in health care costs.”

The American College of Physicians, in its policy paper on Conserving Health Care Resources, similarly called for a transparent process to allocate resources based on evidence wrote:

“There should be a transparent and publicly acceptable process for making health resource allocation decisions with a focus on medical efficacy, clinical effectiveness, and need, with consideration of cost based on the best available medical evidence. The public, patients, physicians, insurers, payers, and other stakeholders should have opportunities to provide input to health resource allocation decision-making at the policy level.”

So, how is that working out in Washington? Well, according to the Times, although many of the expert panel’s recommendations have generated little controversy, the panel’s decision to limit coverage for spinal injections to control pain was compared to “waterboarding and other forms of torture” by a medical journal editorial writer.

I don’t know whether the panel got it right about spinal pain injections. But the Washington state efforts shows the obstacles that will face any effort to limit coverage of medical treatments, even when done in an open and transparent manner with broad publication:

  • Personal stories of patients who claim to have been helped by a particular medical intervention will carry more impact than evidence from clinical trials. Clinical trials are dry, technical analyses that most of the public doesn’t understand. But a patient being denied treatment for something that they swear helps them will trigger an evidence-be-damned reaction from much of the public.
  • Medical device manufacturers have a vested interest in preserving access to their products and will not go quietly into the night. They will seek to ally themselves with patient advocacy groups and physicians who specialize in particular treatments to blunt any effort to deny or limit coverage. And they often will prevail.
  • The experts making the determinations will be attacked for not having the required expertise—meaning that unless they actually perform the procedures being evaluated, it will be said that they don’t understand it and therefore aren’t qualified to issue a ruling. The counter-argument is that physicians with expertise in review of medical evidence don’t have to be trained in a particular procedure to assess the strength of the evidence. And, packing panels with specialists that have a vested interest in maintaining access to a procedure that they perform creates an obvious potential for conflicts of interest. But I expect that much of the public will buy the argument that only those physicians who perform a procedure are qualified to rule on its effectiveness.

David Leonhardt, in a January New York Times Economix blog, compared the public’s views on rationing to Peter Pan’s wish to stay a child forever:

“Opposition to health-care rationing is a little like opposition to growing up. It sounds great. It’s just not very practical.”

It seems to me that Washington state deserves credit for trying to have an adult conversation about how best to allocate limited resources, but is facing a Peter Pan reaction by much of the public and medical profession to its decisions.

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • doc99

    Bob sounds just like Berwick – Ration with your eyes open.
    It all sounds vaguely familiar … ask the Dermatologists who practiced in Germany so many years ago.

    You want transparency? Dump third party payor and get government, insurance cos out of the exam rooms. Publish all prices and let the doctors and patients decide on a course of action free of extraneous encumbrances.

    OK I’m done now.

  • http://www.drdarrellwhite.com DrDarrellWhite

    Was it Oregon or Washington that had a list of medical diagnoses that would be covered by medicaid, ranked in order of coverage? If I recall correctly each year the amount of money spent the previous year would be applied to the following year, and that amount of money would be evaluated to see how far down the list you could cover.

    Rather cut and dried, surely transparent, and definitely numbers based. Imaging the lobbying and jockeying for position on THAT list!

  • Alan D. Cato MD

    Twenty-five years ago, I could never have conceived of saying this,
    but here goes.
    There is more than enough inefficiency, sloppy medical-decision making,
    profiteering and overuse of expensive technology within the current health
    care system that, if immediately eliminated, would result in the quality
    system we all wish for and in savings sufficient for welcoming those without
    coverage into an improved and better quality system—putting Medicare
    back on the road to solvency in the process. This can be achieved but
    only if the government finds the heart and political will for standing up
    to special interests and for intervening in specific instances where
    unbridled capitalism is contributing in equal measure to poor quality of
    care and to out-of-control costs within our health care system.
    For weeding out the expensive and poor-quality practice habits
    increasingly pervasive among physicians in the system today, the
    government would do well to remember that “it takes one to know
    one,”, and, in this case, it will certainly take some to correct some. The
    government will need as its committed ally for this formidable task, a
    sizeable and committed representation from the nation’s practicing
    physicians. While the numbers of this group should be sufficient for
    representing the nation geographically, total numbers are not as
    important for the success of its mission, as would be the group’s
    prevailing medical philosophy including: commitment to evidence
    based medical science, integrity and common-sense. In short,
    government will need as its advisory ally only the most scientifically
    and medically righteous physicians for assuring the mission’s success.
    Physicians qualifying for this committee should share many of the
    same characteristics and principals which defined their predecessors
    during the period when there was still a noble medical profession.
    These should be individuals who went to medical school because of
    their passion for the medical sciences and for the sheer fascination
    with applying them practically for diagnosing and treating illness.
    These should also be the folks who take the Hippocratic Oath seriously.
    The vetting process for this medical advisory committee must be
    meticulous—lest the committee should become contaminated from the
    ranks of their physician counterparts having more self-serving medical
    philosophies and ambitions—thus rendering the committee impotent from
    the-get-go. Hastily comprising a roster of the usual names from medical
    academia will not necessarily be sufficient for keeping out special interests
    or for achieving much-needed, real-world practicality and effectiveness.
    Sufficient time should be taken for truly getting to know the hearts, ambitions and
    medical philosophies of every individual before their appointment,
    since this will be the committee who will help the government identify
    and bring to task the costly, prolific and self-serving decision makers
    among practicing clinicians in the current health care system. This
    should also be the committee who helps the government develop
    clinically sound and cost-effective formularies, clinically effective and
    cost-effective standards of care, and helps define and educate the
    general public as to what constitutes futile medical intervention in the
    context of a number of commonly encountered clinical situations that
    are, due to self-serving clinical decision making, being frequently
    mismanaged throughout the health care system currently.
    In short, this committee must strive to fill the void left, after cultural and
    business interests led to the premature death of the proud and noble
    medical profession!—Alan D. Cato MD, F.A.A.F.P (retired) and author of The Medical Profession Is Dead and the Doctor Is “Critically ill!”

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