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.