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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