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How rationing decisions are made...and how they should be made

Read all of this article. It makes some very good points. However, it offers no real alternatives. Instead of just ranting, we need options. Look at this excerpt:

Virtual colonoscopies are endorsed by the American Cancer Society and covered by a growing number of private insurers including Cigna and UnitedHealthcare. The problem for Medicare is that if cancerous lesions are found using a scan, then patients must follow up with a traditional colonoscopy anyway. Costs would be lower if everyone simply took the invasive route, where doctors can remove polyps on the spot. As Medicare noted in its ruling, "If there is a relatively high referral rate [for traditional colonoscopy], the utility of an intermediate test such as CT colonography is limited." In other words, duplication would be too pricey.

This is precisely the sort of complexity that the Democrats would prefer to ignore as they try to restructure health care. Led by budget chief Peter Orszag, the White House believes that comparative effectiveness research, which examines clinical evidence to determine what "works best," will let them cut wasteful or ineffective treatments and thus contain health spending.

The problem is that what "works best" isn't the same for everyone. While not painless or risk free, virtual colonoscopy might be better for some patients -- especially among seniors who are infirm or because the presence of other diseases puts them at risk for complications. Ideally doctors would decide with their patients. But Medicare instead made the hard-and-fast choice that it was cheaper to cut it off for all beneficiaries. If some patients are worse off, well, too bad.

The research I have seen indicates for screening purposes, the CT colonography is as effective as colonoscopy in detecting colon cancer in the asymptomatic patient. They are also about equal in cost. The availability of CT colonography will increase the number of people who are screened because many people are reluctant to undergo a screening colonoscopy. This should mean that more people are diagnosed early when the survival rate is optimized. CT colonography is much more pleasant for the patient than colonoscopy, but has the disadvantage of requiring a follow-up colonoscopy if an abnormality is found. The vast majority of screening tests are negative.

The real question then is who is at risk for needing that second procedure. It makes more sense to select out patients with significant risk factors for colon cancer and limit them to having colonoscopies. Here is where we need quality, independent effectiveness research. What are the risk factors in an asymptomatic patient that significantly increase the likelihood of a positive screening test?

This is also a case where consumer driven health savings account plans would be helpful. Let the patient decide. Does he want the CT scan and risk having to pay for a second procedure, or does he want the definitive procedure right off the bat? Is the comfort of the CT scan worth the possible extra cost of an additional procedure?

Medicare is not a charity program. These patients have paid money into the system and should get a return on their investment. Medicaid, on the other hand is a plan for the indigent. It is reasonable to require all Medicaid patients to undergo colonoscopy unless there is a medical justification for using CT colonoscopy. Their medical need (colon cancer screening) is being met. Their medical want (comfortable colon cancer screening) is not. This is the un-air conditioned Yugo approach.

As the above WSJ article implies, if the government is the primary provider of health care, none of us will have anything but the un-air conditioned Yugo.


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