Now what does this have to do with Medicare. Well today in the NY Times some cardiologist published a piece stating that there are excess tests. Yes indeed there are, but, there is Monsieur Bayes. Sorry Doctor, but Monsieur Bayes must be paid attention to.
For example the good Doctor states:
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.
Yes, much of this may be not worthwhile but some saves lives. Bayes helps. How? Family history and very soon genetic testing of the type we have been discussing here. So what does one do? Simple, if Bayes says you are at high risk you get paid fully, if Bayes says you are at lower risk the payment is ramped down. Simply we use the risk to adjust the payment, we use information to make decisions, information which is patient specific.
He continues and states:
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. Moreover, colonoscopies carry risks of serious complications (like perforations) and often lead to further unnecessary procedures (like biopsies). In 2009, Medicare paid doctors more than $100 million for nearly 550,000 screening colonoscopies; around 40 percent were for patients over 75.
We use Bayes again. If a patient has a family history, first degree relative with colon cancer and a previous colonoscopy had an adenoma before say 65, then we continue every five to seven years. We can remove a recurring or new adenoms simply, save a life, and reduce costs. Death from colon cancer is not fun, I have seen it a few times so trust me, heart attacks are simple.
He continues:
The full extent of Medicare payments for procedures with no known benefit needs to be quantified. But the estimates are substantial. The chief actuary for Medicare estimates that 15 percent to 30 percent of health care expenditures are wasteful. Medicare spending exceeded $500 billion in 2010, suggesting that $75 billion to $150 billion could be cut without reducing needed services.
Yes we agree and this is exactly what we demonstrated in 2009 in my book of health care policy! So my suggestion is to follow Bayes. You do for those at risk, allow the others to have access but at a lower rate of funding. Never deny someone just put a rational price on it. Also the genetic tests evolving will give much better Bayes tests.
He ends with:
Changing the system would be relatively easy administratively, but would require a firm commitment to determining whether tests and procedures truly benefit patients before performing them. Unfortunately, in a political environment in which doctors providing end-of-life counseling are called death panels, and in which powerful constituencies seek to preserve an ever-increasing array of procedures and device sales, this solution remains hidden in plain view.
Of course, 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.
The last sentence is spot on. Never deny just price accordingly. But pricing should be based on all the evidence, and some due process should be allowed, and more importantly the Government should never, I repeat never, be the collector or arbiter. I fear what would happen with that GS5 with an attitude. The Motor Vehicle Office and IRS are more kindly to a person!
Thus the recommendation, use Bayes, allow the data and testing to change. Then we will see two things, costs will go down and people will be better informed. So will physicians.
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