Three years ago, in January 2007, we wrote a blog (1) about a new “blockbuster” study, the findings of which should have revolutionized cardiology. Results showed that the common procedure of placing “stents” inside heart vessels (at a cost of $15,000 or more each) was no more effective for stable patients, and sometimes more harmful, than taking medication (2). In fact, death rates and repeat heart attacks were even higher in the stent alternative.
What a wonderful discovery for managing medical costs: spend less, get equal or better results, and cause less harm. A trifecta of benefits!
What has happened to the treatment of blocked arteries in the past three years since? Not much. After a brief dip in the rate of stent use, it appears cardiologists now use more stents than ever, ignoring credible evidence. Interviews suggest some cardiologists consider the study not applicable to their patients; or think stents offer quicker relief, which patients want; and fear that if they don’t use a stent, the patient will seek a different doctor (3). As one would expect, there are also debates about whether newer stents work better than those in the study. But that does not change the effectiveness of medication as a safe, effective alternative.
Who should be responsible for implementing this “evidence-based” treatment approach?
Doctors? Cardiologists make ten times more money by inserting a stent than by talking with a patient about medication (4), and The Wall Street Journal reports that the average cardiologist who put in stents has an annual income of $550,000. If their personal experience suggests that stents are safe and effective, what incentive do they have to stop using stents?
Insurers? Insurers don’t want to anger the physicians by reducing reimbursements for stents. As of today, very few insurers have adjusted their reimbursement rules regarding stents, preferring not to risk upsetting members or providers by “getting between patients and their doctors.” Most follow the lead of Medicare, which hasn’t adopted this evidence-based approach yet either.
Medicare? Absurdly, Medicare insurance is legally prevented from considering a treatment’s benefits when deciding how much to pay doctors for doing a certain procedure (4), which leads us to a catch-22: Insurers wait for Medicare to act, but Medicare can’t impose this restriction.
Healthcare shouldn’t cost so much, on this we all agree. So it seems like a no-brainer to have credible evidence to guide our choices about medical care, and the proper value of medical services. For this purpose, $1.1billion of the 2009 Stimulus bill was assigned to conduct “comparative effectiveness trials” (4). Under this effort, a review board called the Federal Coordinating Council for Comparative Clinical Effectiveness Research will identify and disseminate evidence about what treatments work best and are less costly.
Sounds like a great idea, right? In theory, providers better understand which medical procedures are safer and cost-effective and adjust their treatment accordingly, insurers change their reimbursement rates to encourage and reward effective care, and patients achieve better outcomes. Right?
Not so fast.
If credible scientific answers (such as the findings on heart stents) are ignored by providers, insurance AND the same government who sponsors the research in the first place, where do we go for rational decisions?
Rereading the blog from 2007, we concluded that: “As long as cardiovascular care centers make (a lot) more money doing angioplasties (inserting stents) than giving medications—and as long as patients do not pay a portion of the excess cost of a more expensive option—it will be difficult to move medical practice to optimal rates of angioplasty, or any other high-tech procedure.”
It is painfully obvious that none of the major players in healthcare can enforce good evidence; not doctors, not hospitals, not insurers, not government, nor the scientists themselves. And, under normal circumstances—with no financial stake and limited information about price, quality or risk—neither can patients.
Remember, this is one example among thousands and thousands of medical choices. If no stakeholder has an incentive to choose based on effectiveness AND price, it is no wonder that costs continue to grow as they do.
Only one group has the incentive to demand evidence-based care and bring down costs.
Empowered patients are perhaps the only group with the ability to influence and demand evidence-based care. Let’s define them as consumers: patients who spend a portion of their own money for care, and who have access to unbiased information about their options. They are the ONLY party in the equation that can balance the value of expensive-but-instant care against the value of less-expensive, equally-effective but-longer-term options. It’s important to remember that this power to influence care only exists when consumers have both a financial AND a functional stake in the matter, combined with access to information to make good decisions.
An experiment will begin later this year in one health plan where stents will only be covered for non-emergency cases if needed after patients have successfully completed 12 weeks of medication treatment (5). Unfortunately, because patients are not cost-sensitive and physicians have incomes at risk, I fear the most likely result is a media story about unfair rationing or health plans meddling in the sacred doctor-patient relationship. This time, I hope I am wrong.
Why this matters: If consumers paid a higher portion of the cost for non-evidence-based options, the most cost-effective treatments would quickly become preferred by all parties. Providers would have to compete on value and outcomes, rather than piling on the most invasive and expensive options regardless of cost. In the meantime, one can only hope that the health plans that DO promote evidence-based medicine through their reimbursement rules get positive recognition for doing so.
1. Health as Human Capital Foundation. When the Most Expensive Option isn’t the Best Option. Entry 3 – 2007 . 2007 Jan 28: (accessed February 25, 2010).
2. Hochman, J. S.; Lamas, G. A.; Buller, C. E.; Dzavik, V. ; Reynolds, H. R.; et.al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006 Dec 7; 355(23):2395-407.
3. Joffe-Walt, C. Doctors Disagree About Effectiveness, Cost Of Stents. Kaiser Health News; 2009 Aug 27: (accessed February 25, 2010).
4. Walker, E. P. Stimulus Bill Gives $1.1 Billion for Comparative Effectiveness Research. MedPage Today; 2009 Feb 19: (accessed February 25, 2010).
5. Winstein, K. J. A Simple Health-Care Fix Fizzles Out. The Wall Street Journal; 2010 Feb 11: (accessed February 25, 2010).