Should Medicare pay for procedures that have no proven benefit?

“Doctors, with the consent of their patients, should be free to provide whatever care they agree is appropriate. But when the procedure arising from that judgment, however well intentioned, is not supported by evidence, the nation’s taxpayers should have no obligation to pay for it.”

So argues Dr. Rita Redberg, a cardiologist and professor of medicine at the University of California, in a provocative op-ed published in the New York Times. She writes that Medicare “spends a fortune each year on procedures that have no proven benefit and should not be covered” and offers the following examples.

“Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure.”

“The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.”

“Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.”

“Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death . . . Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.”

“A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation.”

If Dr. Redberg is correct that these interventions offer no benefit, why then does Medicare continue to pay for them? She offers several explanations: the contractors who process Medicare claims have no incentive to clamp down on unnecessary procedures, denying payment after a procedure is performed “invites the wrath of both patient and physician” and “our medical culture is such that if the choice is between doing a test and not doing one, it is considered better care to do the test.” (I would throw in defensive medicine as another factor.)

But for Medicare to pay only for care that is necessary and effective, as Dr. Redberg favors, more research will have to be done on the effectiveness of different treatments, and Congress would have to allow Medicare to use such evidence in making coverage determinations.

As a first step. the Affordable Care Act creates a new public-private institute to fund research on comparative effectiveness, but prohibits such research for being used to deny coverage based on cost or to “ration” care. Even so, some conservative lawmakers want to cut off government funding for the institute because they “do not believe that the government can rationally measure effective and ineffective treatments and steer funding away from the latter to the former.”

It is hard to see how the country can make progress to reduce Medicare costs when even a small first step get the evidence on what works and what doesn’t is under political attack, and when denying coverage “invites the wrath of both patient and physician.”

In the meantime, Medicare will continue to “squander” taxpayers’ money by obligating them to pay a fortune each year on procedures that have no proven benefit. If this isn’t the kind of government waste that should make the fiscal conservatives’ blood boil, I don’t know what is.

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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  • Pam Curtis

    On the flip side, I ran into the “it’s not proven, so it’s not covered” problem when trying to get botox for my migraines. I had chronic muscle tension in my neck and shoulders, and botox was proven to work on lower back muscle tension pain. But because it wasn’t “proven,” that is, it hadn’t gone through the bureaucratic red tape to appear in the official Medicare database, I couldn’t get coverage. 

    I couldn’t even get coverage for it once we had proven it’s efficacy.

    When we draw lines in black and white, it’s _patients_ who fall through the cracks.

  • Sandy Peter Wolter

    It its medically necessary The Test should be done  when you go into a Hope they seem to do a lot of test that our not neededin most cases

  • Anonymous

    It is better to not pay for procedures without proven benefit then blindly cutting payments to doctors.  But it is much better to anger a relatively small group of “rich” doctors, then to anger people over 65 who feel that these procedures will make then feel better and get over their illness.

    • Anonymous

      Ah, but not paying for procedures without proven benefit would result in cutting payment to doctors, especially those in highly paid, procedure-heavy specialties.

  • Terence Ivfmd Lee

    Who gets to declare whether something has proven benefit or not? It’s not always that clear (as Pam Curtis’s comment below nicely demonstrates). So is a person sitting high on the political totem pole who gets to decide what is covered and what is not, automatically immune to being swayed by corporate lobbying? In that case, there’s no problem with the bureaucrats and politicians dictating everything as they would be completely trustworthy.

  • Anonymous


  • Anonymous

    Dr. Redberg should leave her lab and offices and work in the real world.  Who decides what is “proven and effective”?  Certainly Medicare isn’t in position to do this because they are paying the bills and have an incentive simply not to pay.  For many many procedures and treatments the issue of effectiveness is subjective.  She pulls out a few examples and thinks that is the point.  She writes not to screen women for cervical cancer if they are 65.  Where did she get this number?  What about 64 a 10 months?  What about 63 and 11 months.  The data that supports these “tak forces” is very limited and politically motivated. 

    • Violetta V

      Actually the task force data is far less politically motivated than the disease advocacy organizations. Task force is an independent entity comprised of doctors and epidemiologists and it makes recommendations based on the available data.  Disease advocacy organizations which promote screening get donations from screening test manufacturers/labs/pharma companies. They also have a very narrow view of only their disease and individual anecdotes. As to 64 vs 65 – one has to draw the line somewhere. How many 65 women you know who are having unprotected sex? If they have a history of normal pap smears, what exactly is the likelihood that they’ll suddenly get an abnormal result? Additionally, how many years it takes for cervical cancer to develop?

      • WhileImHere

        Simply put.  There is no such thing as an independent panel.  More importantly- in the room with a patient- information is shared back and forth that at this time has no entries in a computer database to analyze.  You could read this post in todays Medpage about deskilling.

  • Jupitor Chakma

    If a procedure has no proven benefit, Medicare should not pay for it. 

  • Jupitor Chakma

    If a procedure has no proven benefit, Medicare should not pay for it.  As there are chances of misuse of the facility.

  • Steven Reznick

    I have an eighty year old university professor who runs half marathons for fun and has parents who lived to the century  mark. He has recurring colonic polyps. Are you implying that Medicare should not pay for his colonoscopies because he is over 80?   That would be ignoring his family history and expected life span and putting him at risk. 

    We need to make sure that this efficacy or lack of it touted by consensus policy committees actually is decided by a study that meets the highest standards of the scientific and statistical method before anyone decides anything

  • Paul Weiss

    Patient’s should be given more information to make a better informed decision with.

    How many people would undergo vertebroplasty or kyphoplasty if they had the knowledge that it may not improve their outcome? How many physicians are overconfident in these procedures at best, and overselling these procedures at worst? How many would have a stent placed if they knew it did no better than lifestyle modification and/or medication?

    These procedures are not done in the emergency room. They are elective. Medicare should run a trial whereby patients are advised of risks/benefits/alternatives for such treatments by a source that does not have a financial stake in their performance. It would be interesting to see how much can be saved that way, while not denying someone the right to have unnecessary tests and procedures.

    In my experience as a physical therapist specializing in back and neck pain, I have seen many patients who were driven to surgery without being given proper conservative management first. It’s a travesty.

  • John Fullwood

    I’m the type who’s in favor of a more European style system of health care and even I think that Medicare should only pay for proven treatment. If you want unproven stuff then that’s what private insurance or paying out of pocket is for.

  • Terence Ivfmd Lee

    Sure, let’s logically broaden this line of reasoning to other areas and see what we can learn. As an example, it is assumed by some that forcing airport travelers to remove their shoes and undergo radiological screening and/or palpation-based physical examinations MIGHT make it safer and more pleasant to travel at an efficient cost of providing these services. But is it also at least remotely possible that it DOESN’T? Where are the randomized trials? Yet, people still pay part of their paycheck every month to “support” it and people still “support” particpating it in every time they travel. If we are using as a litmus test “does it have proven benefit” to decide if something should be paid for or not, then there are a whole slew of things in life to which we can apply this question.

    The question posed in this post is important, and if it leads to people engaging in crticial thinking and asking smart questions about other matters as well, it would be even more helpful.

  • Sandra Burrer

    This implies that our “evidence based medical research” is somehow less flawed than medicare reimbursement. 
    Figures don’t lie, but liars figure.
    If medicare wants to improve their bottom line, they need to restructure so that physicians are discouraged from offering expensive, and likely unhelpful, procedures, instead of incentivizing them as they are now.

    • Will Saunders

      physicians ARE “discouraged from offering expensive” procedures already. This is one of the problems. Care is ALREADY being rationed, its just not discussed. Insurance companies essentially penalize physicians for offering a more expensive alternative. Therefore, even if the more expensive alternative is better for the patient, the physician is less inclined to offer it due to fear of penalty by the insurance company. Beneficial care is rationed. 

  • Anonymous

    Interesting overview, Bob, and lively discussion following.   But I’m wondering if your post title here may have it ever-so-slightly back asswards? 

    Instead of asking if Medicare should pay, why are we not more curious about WHY physicians are continuing to  recommend, despite clinical evidence to the contrary, these cancer screening tests, stent and ICD implants, or vertebral fracture procedures that may be either ineffective or unnecessary?  I asked the same question after the journal Public Library of Science Medicine investigated the puzzling insistence of American gynecologists to continue prescribing hormone therapy even after publication of the alarming results of the 2002 Women’s Health Initiative study – the largest randomized, placebo-controlled trial of hormone therapy ever undertaken.  (More on this at “Why Are Gynecologists Still Prescribing HRT Despite Known Risks?” )  The PLoS Medicine review of 340 post-WHI journal articles about hormone therapy revealed that – “Quelle surprise!” -   “…the majority of the doctors who have written pro-HRT papers for medical journals have been funded by the very drug companies that manufacture hormone drugs.”

    • Gil Holmes

      Why do doctors do PSAs even when studies would suggest lack of benefit? Lawyers play a significant role. A few years ago a resident was famously sued(and lost) a malpractice case after documenting the discussion with a patient about the pros’cons of doing PSA testing. The patient decided to not get the PSA. This was all documented and the documentation was not disputed at trial. Down the road the patient had prostate CA. Lawsuit ensued and the resident was found liable as the standard of care was to get a PSA, the studies be damned.

      Heart attacks look bad. ‘Doctor, if you knew the patient had CAD why didn’t you recommend a stent? Might it not have prevented their heart attack?’ You can cite studies all day long. The plaintiff had a heart attack. You might win the case. Heck, you’ll probably win the case. You’ll still spend dozens if not even hundreds of hours in chart review, depositions, trial, etc and spend many hours away from work. The personal financial cost is significant enough(several thousand dollars since overhead doesn’t stop when away) and the emotional cost is of course much higher.

      Kyphoplasty/vertebroplasty does help a small percentage. Recent studies have shown(as I recall) that they are most helpful in the relatively acute setting when pain is not rapidly improving(2-4 week range) but I may be wrong. More studies need to be done. This costs money and the manufactures most assuredly aren’t going to finance them.

  • Kellene Mullin

    What about alternative medicine?  Obviously not as expensive as the procedures you cite, nor am I sure this is something covered by medicare, but many HMO’s cover things like acupuncture, chiropractic, and other assorted treatments not shown to have any proven benefit when compared to a sham procedure.  My point is people seem to *want* procedures done to them and are misinformed about the risks and drawbacks of unnecessary procedures.  For any of this to change, there needs to be a major effort for public awareness that “more medicine does not necessarily mean better health”