OLYMPIA, Wash. — When it's judging the value of medical treatments it pays for, Washington state imposes a tough standard, the kind that might save tens of billions of dollars a year if it were applied nationally.
A panel of medical professionals compares the effectiveness and safety of new treatments and tests with standard alternatives, typically choosing the least costly if there's no real difference. The panel's decisions don't apply to private health plans, but they're binding on 750,000 residents: state employees; people insured by Medicaid, the state-federal program for the poor; and those who are receiving workers' compensation.
The program is unique in the United States, and experts sometimes cite it as a possible model for the federal government. Studies suggest that using this approach would help eliminate inappropriate and wasteful care.
Critics, however, say it interferes with patient-physician decision-making and is a dangerous step down the road to what they consider rationed care, and it appears highly unlikely to gain support in Washington, D.C.
That seemed clear earlier this year when President Barack Obama proposed spending $1.1 billion to compare treatments. Even though there was no decision to use cost as a factor, a firestorm erupted, as some conservatives and industry groups warned that rationing was on the way. The proposal passed only after Congress made it clear that the initiative couldn't be used to dictate decisions about insurance coverage.
Some 3,000 miles away, Washington state's program is proceeding. In three years, its 11-person, part-time panel has made 10 decisions, denying coverage for five services. It's turned thumbs down on virtual colonoscopy for colon cancer screening and knee arthroscopy for osteoarthritis, for example, while approving artificial disc replacement for spinal disc disease under limited conditions. State officials say the program is saving $21 million annually and protecting patients from unproven and in some cases unsafe procedures.
The decisions sometimes have sparked strong criticism. Medtronic, a medical-device maker based in Minneapolis, Minn., was upset when the committee decided against covering implantable infusion pumps for non-cancer pain.
Some doctors also are uneasy about the program. In an interview, Dr. Patrick Halpin, the treasurer of the Washington state association of orthopedists, questioned "allowing a small handful of people to make decisions generally made in the greater medical community."
The legislature has stood by the program it helped create, however, and the state medical association also supports the panel's work.
Congress, by contrast, sometimes gets involved in Medicare coverage decisions. Even though the federal health program for the elderly doesn't have explicit authority to base its coverage decisions on cost-effectiveness, that hasn't stopped its congressional overseers, as well as industry and patient groups, from complaining that adverse decisions might discourage innovation and tie doctors' hands.
The debate over virtual colonoscopy is a case in point. In this non-invasive procedure, a CT scan is used to screen for colon cancer. Advocates say it would entice more people to get their colons checked. Optical colonoscopy, the standard procedure, requires snaking a tube through the colon.
Last year, the Washington state panel decided to deny coverage of virtual colonoscopies. The majority of members found that the procedure works as well as a regular colonoscopy, but concluded that it would cost the state $11 million more a year. The reason: It must be done more frequently and if polyps are found, patients must be referred for regular colonoscopies to remove them. Members weren't swayed by data showing a slight patient preference for the less invasive procedure.
In February, when the federal Center for Medicare and Medicaid Services proposed not covering virtual colonoscopy for Medicare, more than 40 members of Congress pressed the agency to reverse itself. Rep. Danny Davis, a Democrat from Illinois, told the center that virtual colonoscopy coverage was needed to encourage more African-Americans — who suffer a higher rate of colon cancer deaths — to undergo screening.
On May 12, the CMS nevertheless decided not to cover virtual colonoscopies, concluding that there's inadequate evidence to support their use for patients with no symptoms and at average risk of colon cancer. It called the technology "promising" but said that more studies with older patients were needed.
Medicare administrators appeared to bow to pressure last year when they withdrew a proposed decision to limit coverage of a screening test for heart disease — coronary CT angiography — after facing criticism from Congress and medical and patient groups. They concluded that there wasn't sufficient evidence of improved health outcomes.
The Washington state program faces less political pressure in part because it has strong political backing and its impact is limited to one state.
The technology assessment panel comprises six physicians from different specialties, a nurse practitioner, a chiropractor and a naturopath; there are two vacancies. According to Leah Hole-Curry, who heads the program, state agency directors and patient, physician and health industry groups suggest services for evaluation, based on red flags such as questionable outcomes and unexplained variations in how frequently a service is used.
The panel commissions lengthy evidence reports from the Oregon Health & Science University and from Spectrum Research in Tacoma, Wash. These researchers examine published medical-journal studies on each topic and rate the quality of evidence. This work anchors the panel's deliberations, although interested groups and the public can make comments to the panel and attend its meetings. No patients or doctors testified on virtual colonoscopy.
"It's a tremendous responsibility because we're saying whether people can have access to various technologies," said committee member Louise Kaplan, a nurse practitioner and assistant professor at Washington State University in Vancouver.
Assessing cost-effectiveness is particularly tricky, Kaplan said, because there aren't a lot of good studies on how much money a treatment saves in the long run. If children receive gastric bypass surgery to reduce obesity, for example, will it be cheaper to care for them 10 years later if they aren't suffering from diabetes and heart disease?
Democratic Gov. Christine Gregoire proposed the program to help improve the affordability and quality of health care. The state already had a similar program for drugs. The drug committee's decisions aren't binding, though state agencies often adopt them.
Perhaps the biggest controversy so far arose over the committee's decision last year not to cover implantable infusion pumps for pain that isn't related to cancer.
The committee found strong evidence that the pumps are unsafe, and weak evidence of significant pain relief. In an e-mail response to questions, Medtronic, which dominates the infusion pump market, emphasized the need "to identify the best outcome for patients and preserve physician choice in using their best medical judgment."
Medtronic lobbied Washington state lawmakers this year to change the program, including expanding the role of manufacturer and patient groups and providing an appeals process, but a Senate bill to revamp the program died in committee.
The panel's latest decision, on May 8, was a tough one: whether to cover drug-coated cardiac stents as an alternative to less-expensive bare metal stents for keeping cardiac arteries open. After a grueling day of analyzing numerous studies and listening to testimony from doctors and one patient, the committee voted to continue covering bare metal stents and to limit drug-coated stents to people with the highest risk of reblockage.
The decision very likely will affect large numbers of patients and physicians, as well as stent makers, and it probably will draw criticism from those who favor using drug-coated stents more widely. There'll be another public comment period, and the panel will decide whether to ratify its decision in August.
Spokane family physician Brian Budenholzer, the chairman of the panel, said this was one of the toughest calls so far because drug-coated stents were a little better for some patients but cost a lot more. He said the panel struck a good balance, though he acknowledged that the decision "won't be universally applauded."
He predicted that the rest of the country eventually will follow Washington state's model because the U.S. can't afford to keep paying for everything new that comes along, whether it has value or not. "If the country isn't ready to do this now," he said, "they will be."
ser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care-policy research organization that isn't affiliated with Kaiser Permanente.)
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