A Modest Proposal: Pay More for Care Only if It's Better

Cheryl Clark, for HealthLeaders Media , October 7, 2010

Indeed, some now question the efficacy of a variety of expensive spinal fusion surgeries that are invasive, cause a higher rate of infections, require longer recovery time and often do not resolve pain after two years any more than if the patient were given medications and physical therapy.

Bach and Pearson acknowledge that changing Medicare's approach to coverage and reimbursement could require even more legislation and authority. And it would, they wrote, "be highly contested by those with a vested interest in existing reimbursement systems."

But they are guardedly optimistic for four reasons:

1. Medicare's ballooning costs must be tempered.

2. The idea of paying equally for comparable results resonates with patients and policymakers. 

3. State Medicaid programs and private insurers could be first adopters with lessons learned from smaller scale approaches.

4. Such a policy may not need legislative overhaul at all, but might be woven into the regulatory process.

During our chat this week, Bach conveyed his frustration with what the authors described today's "perverse" system of payment incentives.

"What new technologies do we want disseminated if the justification for disseminating them is just that they get a higher reimbursement rate?" he asked. "To us, a higher reimbursement should come with greater effectiveness, not 'just because....' "

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1 comments on "A Modest Proposal: Pay More for Care Only if It's Better"

Susan Collingwood (10/21/2010 at 3:01 PM)
This proposal sounds like a fantastic way to gut medical innovation. True, evaluation of care results needs to be done. HOWEVER, the Randomized Clinical Trial model has *significant* flaws. In the cancer example cited, it often takes 10 YEARS or more to get meaningful data on "ultimate outcomes". Further, the proposal basically suggests physicians request patients to voluntarily subject themselves, for example, to *ADDITIONAL RADIATION* (that we already know is bad for them[INVALID]that's why we strive to limit it!) on the *off chance* that the additional radiation we know the patient will receive in conventional radiation therapy is not that harmful, despite the known improvement in reduced tissue irradiation in IMRT, and huge improvement in proton beam. This does not, of course, even take into account the reasonable expectation that the IRMT or proton beam therapy may actually have a better outcome in curing the cancer! Further, in evaluating the treatment, the author's proposal suggests that *without* a RCT, one is free to ignore other evidence (like physics involved), since it's not a RCT with a defined endpoint. Because newer care is often more (or even much more) expensive than existing care (due to additional costs of technological innovation, or even needed physician time [see the comparison in Dr. Gawande's book, "Better", between the care delivered by the CF programs[INVALID]and note the mortality experienced), the threat of not having reimbursement until a RCT (in the case of the cancer sited, of at least 10 years) is completed is VERY likely to entirely stifle medical innovation.




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