Doctor and Patient, Now at Odds

Today's NY Times Health section has a disturbing item about what I think we all have been noticing: patients are losing their trust in doctors. Personally, I think that this article only scratches the surface of the issue, especially at the causes:

The reasons for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive.
“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”
Others say the problem also stems from a grueling training system that removes doctors from the world patients live in.

Personally I think the problems are much more to do with the external pressures on physicians (e.g. insurance companies trying to optimize profits by limiting access to testing and services and potential malpractice suits) than their training or even the limited time.
Would love to hear from the group about this...
Gil

Means Testing, for Medicare

The NY Times had a piece on "Means Testing" for Medicare last week that I think is very topical for our group. It brings up an issue that is potentially one of the greatest domestic political liabilities, and one that almost every politician has been avoiding. As the NY Times’ Tyler Cowen points out, none of the healthcare reform proposals by the presidential candidates (nor most of the Congressional candidates either) even identify Medicare solvency as a problem, let alone have a proposal for a fix.
The use of “Means Testing” — cutting back on payments to the relatively wealthy, has been a proposal that has been around for a while, but, as the is pointed out:

The biggest problem with such efforts is measuring and enforcing the rules that establish who receives a specified benefit and who doesn’t. Means testing in Medicaid causes many people to hide income and assets or to transfer assets to family members, so they can look poorer and still get benefits.

And...

Of course, the idea of cutting some government transfers provokes protest in some quarters. One major criticism is that programs for the poor alone will not be well financed because poor people don’t have much political power. Thus, this idea goes, we should try to make transfer programs as comprehensive as possible, so that every voter has a stake in the program and will support more spending.

Although I agree with Mr.Cowen that this Medicare issue needs to be addressed. I completely disagree with his point that:

Advocates of health care reform tend to be long on ideas for expanding care and access, but short on practical solutions for cost control. The argument is often made that single-payer health care systems in Canada or Europe are cheaper than health care in the United States. But Medicare is already a single-payer plan, yet its costs are unsustainable.

This, as we have previously pointed out, mislabels current Medicare as a public, single payer plan. In fact, current Medicare is a complex hybrid that is as much private as it is public. It should never be mistaken as a "single payer" system.
The fact is that a single payer system would take care of this aspect of spending by rationing services as the economic status sees fit. The issue is how to make sure that this rationing is done in a way that allows for the best health of the nation, yet does not restrict access to services to those who would like to pay for them out-of-pocket or through private insurance.
This is where the HPfHR plan has a solution: every one is covered for basic services while allowing for "means testing", preventive services incentives and other methods to improve efficiency while improving the health of the nation.
Gil

Healthcare Professionals for Healthcare Reform

Have you heard of this group, at http://www.pnhp.org/? I wonder if their similar-sounding name to Healthcare Providers for Healthcare Reform implies a similar perspective?
-Ryan

Article in American Journal of Medicine

Interesting commentary in the most recent American Journal of Medicine co-authored by the journal's editor in chief. What's interesting is not the content, none of which is surprising, but the fact that it's the topic-du-jour. Its presence suggests that this is a good time to talk about ideas for Healthcare Reform in the medical literature.
-Ryan

Screening for risk factors or detecting disease.

Here is an interesting report I read on theHeart.org, that is very germane to the subject of prevention and should be of significant interest to our group. It talks about the controversy in the cardiology community that is dividing those in favor of risk-factor screening and prevention on one side from those who advocate early screening for the disease itself.
Although there are many issues here, this ultimately boils down to the controversy between evidenced based information (screening for risk factors) and not yet proven, but compelling diagnostic techniques. I think that the whole argument for me can be summarized by Greenland's statement near the end:

"So I think the only way that this issue is going to get resolved is not by editorials or opinions like mine or Jay Cohn's but by more data, and the data that are needed are clinical trials."

That would be the view of the "Board" in the HPfHR plan as well.
Gil

Preventive Medicine Incentives

One of the major goals of healthcare reform is to make preventive service more available. During a recent telephone conversation with new member David Katz, MD, MPH, we discussed how the HPfHR system could promote preventive services.

Dr. Katz, who has published extensively on preventive services in the medical and lay press, sent me a couple of interesting pieces that discuss the under-utilization of preventive services.

In 2006 he wrote:

Most of us surely agree, in theory, that when it comes to disease, an ounce of prevention is worth a pound of cure. But a new report entitled "Priorities for America’s Health: Capitalizing on Life-Saving, Cost-Effective Services," released last week by the non-profit Partnership for Prevention, suggests that our actions are often at odds with this philosophy.
The report indicates that many vital preventive services are seriously underutilized. The consideration of aspirin to prevent heart disease, for example, is often appropriate in men over age 40, women over age 50, or anyone with heart disease risk factors; yet the topic is only discussed with about 50% of these at-risk individuals. For someone who smokes, quitting is among the best things they can do for their health, and available evidence suggests that physician counseling is a helpful inducement. But only about 35% of smokers receive this professional guidance.
Screening for colon cancer by any of several means has life-saving potential in anyone over age 50, yet is provided to only 35% of this population. The pneumococcal vaccine can prevent one of the most common forms of bacterial pneumonia, and is advisable for all adults age 65 and older; but nearly half of this population is unimmunized. Screening young women for the common sexually transmitted infection, Chlamydia, can prevent further transmission, along with both serious illness and infertility- but 60% of sexually active women under age 25 are unscreened.
The report characterizes not only which preventive services are under utilized, but which, when used, offer the most "bang" for the buck. Beginning with the scrupulous assessments of the utility of preventive services compiled by the United States Preventive Services Task Force, this new report assigns priority scores for 25 preventive services based on their health impact and cost-effectiveness. Each of these is on a scale from 1 (lowest priority) to 5 (highest priority), and the two scores are summed.
Discussion of aspirin use to prevent heart disease, screening and counseling for tobacco use, and childhood immunizations all received a score of 10, making these top priority items. Screening for colon cancer, monitoring blood pressure, flu vaccine, pneumonia vaccine, screening and counseling for alcohol abuse, and vision screening for older adults were close behind with scores of 8. The full list is available at www.prevent.org/ncpp.

In 2007 he added this:

The leading causes of disability and premature death in our society are overwhelmingly preventable. There is consensus among experts that applying what we know now would enable us to prevent 90% of diabetes, 80% of heart disease, and up to 60% of cancer.
What if we dedicated funds to insuring every person in the country (or a given state), but then required them to put that coverage to good use? The United States Preventive Services Task Force (http://www.ahrq.gov/clinic/prevenix.htm) is a non-partisan group of medical experts who conduct exhaustive reviews of the evidence supporting clinical preventive services, such as immunization, cancer screening, and counseling for healthful eating, exercise, and weight control. The reviews of the Task Force illuminate a whole list of services we know not only to promote health and prevent disease, but also to be cost-effective. And other groups have taken this effort further, examining the impact of preventive services relative to one another. Former US Surgeon General Dr. David Satcher lead a group called the National Commission on Prevention Priorities that rank-ordered preventive services on the basis of bang for the buck. Topping their list are aspirin to prevent heart disease, childhood immunization, and counseling for smoking cessation (see http://prevent.org/content/view/49/99/ for the complete list).
Since we have cost-effective means of preventing advanced disease, why not impose on ourselves the responsibility of using them?
How about this: you are guaranteed health insurance only as long as you are substantially in compliance with recommended clinical preventive services? No need to require perfect compliance, but a minimum of, say, 80% of recommended services for your household during any 3-year period, might be reasonable. Published reports indicate that at present, clinical preventive services are substantially under-utilized.
The advantages of people receiving clinical preventive services are considerable. Lives will be saved, cases of advanced disease prevented by virtue of early detection and treatment, and costs reduced. If all clinical preventive services were used as advised, hundreds of thousands of lives could be spared each year, and health care expenditure reduced by $100 billion or more.
A recent report in the NY Times (To Save Later, Employers Offer Free Drugs Now. by Milt Freudenheim. NY Times. 2/21/07) indicates that some companies will provide medications to their employees for free to treat chronic disease. This is advantageous to the employers because well-treated chronic disease is less costly than poorly treated chronic disease. Co-pays reduce an employer’s drug costs, but the evidence is clear and consistent that they drive up total healthcare costs by reducing medication use. So paying the pharmacy bill to ensure that employees actually take drugs as prescribed turns out to be good business, as well as good medicine.

After reading and discussing the HPfHR plan, he suggested that we might be able to encourage preventive services for everyone by (public) financing Tier 2 coverage for those who show more than 80% compliance with their Tier 1 preventive screening services.
I personally think this will be a great addition to the plan and will dove-tail well with our aim to improve the health of the entire population.
Please let me know if you have any other thoughts or comments.
Gil

Medicare Showdown

I think that this over-ride of the Medicare bill is going to be a landmark for healthcare reform. To underscore it's importance, I just noticed that the New England Journal just issued it's web edition and there is a very interesting analysis of the veto over-ride vote that just occurred yesterday (talk about up-to-the-minute!). As with the Krugman Op-Ed and the New York Times editorial (not to mention our own blog post), this NEJM "Perspective" sees this as good for physicians and for Medicare.
I personally also feel that this over-ride may be a turning point in what I believe is an outright war against Medicare and other publicly financed healthcare by the current Federal administration. Until this vote there has been an all-out push to "privatize" all aspects of Medicare, giving every advantage to the private sector so (and I believe this was a deliberate aim) that "public" Medicare will collapse.
Now, I know that Medicare is not perfect, but I think that many of us in the health care delivery end of the issue see that "public" Medicare is more user friendly to both patients and healthcare providers and is more fiscally efficient. In fact, the introduction of these "privatized" plans have only benefited the health insurance industry and made our jobs more difficult (as with the introduction of "pre-approvals" for Medicare patients) and have driven up costs.

Getting back to the NEJM piece; it closes with this;

Although the temporary fix for physician fees will alleviate the immediate concerns of many doctors, the remuneration problem remains unresolved for the longer term. No one is satisfied with the current formula by which Medicare calculates physician fees, but Congress has hesitated to act because of the hefty price tag that would be attached to any change deemed acceptable to both policymakers and physicians. Members of Congress have urged physician groups to develop their own proposals, but because any viable plan is certain to result in both winners and losers, organized medicine, too, has been reluctant to act. So for the time being, annual Band-Aids will continue to be the standard of care for Medicare's physician-payment woes.

So I want to thank Congress for this important vote!... but at the same time it is clear that there is still a great need for a new politically viable system.
Gil

Medicare’s Bias

One of the alternatives to a single payer universal healthcare that has been proposed by Yale's Mark Schlesinger and Jacob Hacker (Hacker has been a key adviser to both the Clinton and Obama campaigns on health policy and also was an adviser in the Massachusetts plan) is an expanded Medicare system. The thinking is that since a single payer system is not politically viable, we need a public/private partnership for healthcare. Their proposal is quite long but well thought out Secret Weapon: The “New” Medicare as a Route to Health Security, Journal of Health Politics, Policy and Law, Vol. 32, No. 2, April 2007) and basically argues that this public/private partnership already exists in modern Medicare. After discussing the merits of an expanded public/private hybrid like Medicare they have the following discussion:

Although competitive hybrids have attributes that can enhance their effectiveness
and political stability, it is important to recognize that this program design also embodies some sources of tension. Precisely because competitive hybrids allow for public and private insurance to coexist, partisans of each will constantly contest the appropriate boundaries between the two and seek to amend the program in ways that favor their preferred form of insurance.
These ongoing political tensions can reinforce some of the administrative challenges inherent in a program that combines public and private insurance. Programs that offer beneficiaries a choice between the two forms of insurance have typically experienced favorable selection by private insurers, who adopt practices that encourage enrollment by relatively healthy beneficiaries and disenrollment among those who are chronically ill (Medicare Payment Advisory Commission [MedPAC] 2000). In the short run, these patterns of selection lead to slightly higher costs
for a hybrid program than for pure public insurance.
The longer-term political implications, however, may be more consequential. Were hybrid programs to adopt policies of fixed contributions (socalled “premium support”
arrangements), existing cost differentials could induce more beneficiaries to select private plans, even if their performance was no better than conventional FFS Medicare (Oberlander 2000). If politicians view the higher costs in the public component as an indication of inefficiency rather than selection, they could lose faith in the public component and try to move beneficiaries and resources to private insurers.

Well, today there was an editorial in the NY Times that we feel confirm these limitations of inherent competition in modern Medicare, and why we believe it may be difficult to simply expand Medicare. Instead of having the private and public system co-exist, we believe that they need to be separated. In our system, private and public coverage exist together (allowing for universal coverage) but separated so that there is no inherent competition.
Gil

Another Chance for Universal Healthcare?

Paul Krugman, an Economics Professor at Princeton and a regular NY Times OP ED columnist, had an interesting OP ED in the Times on Friday. Although it was titled "Kennedy’s Big Day " and started off discussing how Ted Kennedy came out of his convalescence to save Medicare (and doctors), he went on to discuss how this vote was a very good harbinger for the political viability of universal healthcare. A recommended read.
Gil

McCain's Plan

This was on Health08.org today, (a great site run by the Kaiser Family Foundation for a non-partisan look at health care policy):

The New York Times on Wednesday examined a plan by presumptive Republican presidential nominee Sen. John McCain (Ariz.) to expand high-risk health insurance pools as part of his plan to provide greater access to health insurance in an "invigorated individual market." High-risk pools, now based in states, generally help individuals who cannot obtain private coverage because of pre-existing medical conditions or no previous group coverage.According to the National Association of State Comprehensive Health Insurance Plans, such pools have existed for 30 years and cover about 207,000 U.S. residents. "Premiums typically are high, as much as twice the standard rate in some states," but they "are still not nearly enough to pay claims," which has left states to cover about 40% of the cost of the pools, "usually through assessments on insurance premiums that are often passed on to consumers," according to the Times. "Health economists say it could take untold billions to transform the patchwork of programs into a viable federal safety net" as McCain has proposed in his Guaranteed Access Plan, the Times reports. However, the "McCain campaign has made only a rough calculation of how many billions would be needed and has not identified a source for the financing beyond savings from existing programs," and efforts to finance his proposal "will only get more difficult now that McCain has pledged to balance the federal budget by 2013, which already requires a significant reduction in the growth of spending," according to the Times. Cost Douglas Holtz-Eakin, chief domestic policy adviser to McCain, in April estimated McCain's health plan would cost the federal government $7 billion to $10 billion, with five million to seven million uninsured residents targeted for coverage. However, Holtz-Eakin recently said that the cost "could change dramatically" based on the plan's structure. Holtz-Eakin and other McCain health care policy advisers -- such as Thomas Miller, a resident fellow at the American Enterprise Institute, and Stephen Parente, a health economist at the University of Minnesota -- said that the plan likely would cap premiums at twice the standard rates, with subsidies possible for residents with annual incomes less than 400% of the federal poverty level. In addition, financial incentives "would probably be provided to those who effectively manage their diseases," according to the Times. "McCain's proposal would represent a huge increase over the $50 million a year that Congress now appropriates in grants to the state pools," but "several analysts questioned whether even $10 billion would be nearly enough, given that the states now spend about $2 billion to insure 207,000 people," the Times reports. Karen Pollitz, a professor at Georgetown University who has studied high-risk health insurance pools, said, "They are run in ways that protect the profitability of commercial insurers," adding, "They leave the illusion that there's a safety net without there really being much of one"

Gil

Health Care for America Now and Divided we Fail

There have been some interesting developments in the political front that may be of interest to the group. First, I came across an item in the NY Times about a group that is spending $40 million dollars to promote healthcare reform. It's lead spokesperson is Elizabeth Edwards and it was difficult to figure out what plan the group was actually promoting. I finally found the following (but lost the source):

Groups Seek To Promote Health Care as Campaign Issue
Advocacy groups plan to spend more than $60 million to promote and ask presidential and congressional candidates to support proposals to expand health insurance to all U.S. residents, the AP/Houston Chronicle reports. Health Care for America Now, a coalition of labor unions and other organizations that support Democrats, plans to announce a $40 million national ad campaign that calls for access to affordable health care for all residents. The campaign will target important Congressional districts in 45 states and will ask candidates to support proposals that allow U.S. residents to retain their current health insurance, purchase new coverage or enroll in a health plan administered by the government. Richard Kirsch, campaign manager for Health Care for America Now, said, "The whole goal is to create a mandate next year for the president and Congress to enact health care reform that meets our principles."Meanwhile, AARP on behalf of Divided We Fail -- a coalition led by AARP that includes the Business Roundtable, the National Federation of Independent Business and the Service Employees International Union -- plans to spend more than $20 million through Labor Day to promote bipartisan proposals to make health care more affordable. AARP Executive Vice President Nancy LeaMond said, "We felt we needed more than policy ideas, but the political will to actually get something done." Neither of the coalitions plans to endorse a presidential candidate, although a number of the groups in Health Care for America Now have endorsed presumptive Democratic presidential nominee Sen. Barack Obama (Ill.) or have members serving as his advisers (Kuhnhenn, AP/Houston Chronicle, 7/8).

I think it may be important for us to look into both of these initiatives, since neither the Healthcare for America Now or the Divided We Fail coalition seem to have a specific plan. Also, both have stated that they are not supporting one candidate's plan over another. This may be an entree for our group's plan.
Gil

The Senate Stalls on Medicare

If further proof is needed that the system is broken, everyone should read the NY Times editorial today regarding how special interests (i.e. the insurance industry) is holding up what is clearly good healthcare legislation. In case you have trouble with the link above I will copy it:

The Senate Stalls on Medicare- July 5, 2008
Before leaving town for the Fourth of July recess, Senate Republicans thwarted a vote on a sensible Medicare bill that would benefit doctors and patients at the expense of overpaid private health plans.
The House approved the legislation with a vote of 355 to 59. The bill is supported by most doctors, hospitals and pharmacists. But it is vehemently opposed by the insurance industry and its Republican coddlers.
The bill would protect doctors from a 10 percent cut in their reimbursement rates, and it would give them a tiny increase next year. It would also spend more money to enhance preventive services, improve low-income assistance programs and make other modest but worthwhile changes. The bill would largely and sensibly offset the additional costs by reducing payments to the private plans that participate in Medicare.
That has inflamed opposition from the White House and Senate Republicans who seem determined to protect inefficient private plans from the rigors of competing fairly against traditional Medicare coverage. Medicare pays these private plans, known as Medicare Advantage, an average of 13 percent more to provide the same services as the traditional Medicare program.
The new bill would start reducing the payment disparity through some modest adjustments. It would also require the fastest-growing category of private plans — private fee-for-service plans — to organize networks of doctors and hospitals and report measures of quality, just as other private plans do, so that beneficiaries would have guaranteed access to capable medical providers.
The likely result would be slower growth for the private fee-for-service plans, which are the most heavily subsidized and least efficient Medicare plans. That is an outcome to be welcomed, not deplored.
We would prefer eliminating a provision that would postpone a promising new competitive bidding program for durable medical equipment. But even with that weakness, this bill needs to pass so that Congress can start the politically difficult task of wringing unjustified subsidies from the most inefficient private Medicare plans.
In the Senate, every Democrat (except the ailing Edward Kennedy, who was not there) voted to take a final vote on the bill. Nine Republicans went along, leaving the bill only one vote short of forcing a vote and up to eight votes short of a veto-proof majority.
Every American represented by one of the recalcitrant Republican senators should press them to change their votes. Medicare is in deep financial trouble. Voters should demand that their leaders help control spending by reducing clearly unjustified subsidies to private Medicare plans. Let them compete on a level playing field with the government-run Medicare program.

This is why we need an independent Board (as in the HPfHR plan)
that will be able to avoid the whims of Congress.

In the mean time it is important to do as the Times asks and: "Voters should demand that their leaders help control spending by reducing clearly unjustified subsidies to private Medicare plans. Let them compete on a level playing field with the government-run Medicare program. "
GIL

Weighing the Costs Part II

I came across this in the Financial Times. It reviews the pros and cons of the argument that technologies help increase healthcare costs. I think that the argument that it does not really increase healthcare costs, lose out when the example of the CT angiograms are pointed out. As we pointed out previously, the current system is very susseptable to pressures from industry and physicians even when the "system" (i.e. Medicare in the case of CT angios) is trying to do the right thing. Again, I think that the HPfHR model, with a semi-independent Healthcare Board modeled after the Federal Reserve, would be able to withstand these pressures much better and help control cost more effectively.
Gil

New signup

Gil,

Thanks for setting up this blog, it was easy to sign up for, and will leave a nice record of opinions without clogging up the main site. Charles Kochan. (I am also testing to see if it posts my first entry!) ps it worked...........

Connecticut Launches Health Plan For Uninsured

Some have asked about Connecticut's new plan. I have to say that I am not as familiar as I should be with the details, but here is a link to the Hartford Courant on the subject.

On first blush it looks promising, but the devil's in the details. I again need to plead ignorance and say that what I know is what has been written in the media. Although there are many benefits, the Courant article does not discuss specifics about how or even if the private insurance plans are regulated. It is also worth to note that this is not universal coverage and some things we would consider Tier 1 conditions (under the HPfHR plan) such as diabetes will not be covered. Finally, I don't see how costs are to be contained with this plan.

Does anyone have more knowledge of this plan?
Gil

Weighing the Costs of a CT Scan’s Look Inside the Heart

Many have asked me about the front page article in the NY Times last Sunday (June 29th) about CT angios. I have been meaning to comment all week, but this has been a busy time (as the new hospital-academic year started yesterday). It is long and involved, but I think it does cover most of the issues about CTA fairly even-handedly.
From our standpoint , I think this is a very nice example of how the HPfHR model could work well to both control costs and to get evidenced based information that will help the population.
Consider the final section of the article:

Medicare’s Scrutiny
The Centers for Medicare and Medicaid Services had decided to push back.

The agency, which this year will spend more than $800 billion on health care, rarely questions the need to pay for new treatments. But last June, Medicare said it was considering paying for CT heart scans only on the condition that studies be done to show they had value for patients.

Concerned about the overall proliferation of imaging tests, Medicare said it might require a large-scale study to determine the scans’ value.
The plan met with fierce resistance, particularly from a relatively new organization of specialists, the Society of Cardiovascular Computed Tomography. The society has 4,700 physician members and one purpose — to promote CT angiograms.
“For the CT society, this was life or death,” said Dr. Daniel S. Berman, the group’s president-elect. “This decision could essentially put them out of business.”
Galvanized, at a meeting in November in Chicago, the CT specialists vowed to overturn any possible Medicare proposal.
“We didn’t need to be talking about registries and the research,” Dr. Berman said. “We needed to be questioning the wisdom of the Medicare decision itself.”
The next month, Medicare issued the draft of its proposal, saying that it would pay
for the scans only if a large-scale study were conducted. The CT society, along
with other prominent medical groups whose members performed scans, set to work
lobbying the agency and members of Congress.
One group marshaled the evidence the doctors would take to Medicare, arguing that the agency had ignored some studies, including those of the new 64-slice CT scans. Another group visited Congressional offices. Defenders of the technology argued that Medicare had agreed to pay for other tests, like mammograms, without requiring proof that they improved patient care. Breakthrough technologies, they said, need time to prove themselves.
Medicare “set the bar so high, no new technology would be able to survive,” said Dr. Michael Poon, a New York cardiologist who is the CT society’s current president.
Cardiologists met with Representative Carolyn McCarthy, a New York Democrat. In March, she and other members of Congress wrote to Medicare, urging it to reconsider its plan. Eventually, a dozen or so senators and 79 representatives lined up to support the society’s efforts.
And Medicare gave way.
“There are a lot of technologies, services and treatments that have not been unequivocally shown to improve health outcomes in a definitive manner,” Dr. Barry Straube, Medicare’s chief medical officer, explained when announcing that the agency would keep covering the tests.
In other words, the lack of evidence that the CT scans provide measurable medical
benefit would not stop Medicare from paying for them.
Heavy lobbying makes it virtually impossible for the agency to insist on more evidence before agreeing to pay for a new technology, said Dr. James Adamson, chief medical officer for Arkansas Blue Cross and Blue Shield. “Medicare,” he said, “does not make a lot of really hard decisions.”

I, and I say this as a cardiologist, completely agree with CMS's (i.e. Medicare) original decision not to pay for CTAs unless it was part of a study or registry that would determine it's usefulness, cost effectiveness and appropriate use. I was very upset that they caved in to the special interest groups. In the HPfHR model the Board, set up like the Federal Reserve Board, would be much more resistant to this sort of pressure. Yet it would not completely deny access to CT angiograms. Like CMS's original suggestion, the Board might make a CTA a Tier 1 indication if it was part of a appropriateness study. Alternatively, it may decide to fund or underwrite an appropriateness study with industry. But since the Board will be much more insulated from political and special interest pressure, it is more likely this will be implemented.

Gil

BTW: the online version of the NYT article has a great video of CT angiogram.