Friday, September 9, 2011

Medicare Did It Right, Again

For those who believe Government cannot do anything right I offer this example of a Government program that has done quite a few things right. The agency is the Center for Medicare and Medicaid Services (CMS). Boy that will explode a few right wing heads.

Six years ago the FDA approved, in an expedited process, stent devices similar to the stents used to open heart arteries that are plugged up with cholesterol plaques for use in preventing strokes and more specifically recurrent strokes. It seems intuitive that if it helps in heart disease and the problems in stroke are very similar it should help in stroke as well. It just isn’t that simple.

CMS knew it was not that simple. Since most strokes caused by cholesterol plaques occur in older patients Medicare was likely to be responsible for much of the cost of the new therapy. Standard medical therapy consists of strict control of blood pressure, strict control of diabetes, control of cholesterol/lipid levels, drugs to reduce the ability of blood to clot, cessation of smoking and life style changes.

CMS refused to pay for the stent treatment unless it was done for a controlled study to prove the stents would be effective. So a study was devised where matched patient populations were all given the intensive medical management and half were also given the stent after appropriate disclosure that it was a new procedure study. Adding the approved stent (Wingspan stent) would add $88,000 to the $24,000 cost of the intensive medical management.

The study found the stent produced no long term benefits and was statistically similar to the medically treated group after the immediate post operative period. The stent, however, was associated with a large increase in death and recurrent stroke in the immediate post operative period.

It is possible that further studies will find a niche for the stent in a rigorously selected group of patients. Stents for atherosclerotic heart disease went through a period of reappraisal. It is still the object of some skepticism and will undoubtedly continue to be studied and its indications for use will be refined.

Still, the indiscriminate use and the additional $88,000 cost will not be a factor in Medicare inflation. CMS did the taxpayers a great favor. Not only in protecting the Medicare funds from more rapid depletion but in influencing the private insurance industries costs. When Medicare makes this kind of move the private insurers almost always follow quickly. Medicare gives them cover for excluding this kind of unproven therapy from coverage.

Think of the vast number procedures and treatments that are no more than intuitively performed in this country that should be examined critically. That is the purpose of the section of the Affordable Care Act concerned with comparative effectiveness. You know, the part that Republicans demagogue as the rationing of care.

Ref. Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis:
Brain Stents do more Harm than Good, Rob Stein

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