The New York Times
March 21, 2011
A Panel Decides Washington States Health Care Costs
By ANDREW POLLACK
SEATTLE The health care board was in session, and Deryk Lamb was pleading for them to continue paying for the spinal injections he receives to dull the pain from a workplace injury.
My life would be a living hell without these injections, said Mr. Lamb, a 44-year-old carpenter from Lake Stevens, Wash., who was crushed between two trucks in 1996. I dont deserve to be sentenced by a committee to a life of agony.
Mr. Lamb was testifying on Friday before Washington States Health Technology Assessment committee. The committee has authority under state law to determine which medical devices and procedures Washington will cover for state employees, Medicaid patients and injured workers, about 750,000 people in all.
While all states, private insurers and the federal Medicare program decide what to cover, this states program is attracting nationwide attention, in part because its process is public and open. That provides a living laboratory of the complexities of applying evidence-based medicine, something that is becoming more common as a way to rein in health care costs.
This kind of scrutiny is increasingly the norm, rather than the exception, said Dan Mendelson, chief executive of Avalere Health, a consulting firm that follows state and federal health programs. Washington States effort, he said, was unique in the size and breadth of it.
The program is also drawing attention because it explicitly considers the cost of treatments in making its decisions, akin to Britains National Institute for Health and Clinical Excellence.
That similarity alone has made the Washington program the target of criticism from opponents of the new federal health care legislation. Last Friday, The Wall Street Journals editorial board, a longtime opponent of the federal law, called Washington States process a harbinger of limitation of choice that it said would result from the national health care overhaul, which includes undertaking efforts to compare the effectiveness of different therapies.
Criticism is also coming from doctors and manufacturers hurt by the decisions.
An editorial in one medical journal in the pain-control field equated one of the committees decisions to waterboarding and other forms of torture, showing a photograph of a chair with numerous metal blades protruding from it.
Medical device manufacturers are lobbying for changes in the program.
I think there is evidence that other states look at what they do, said Rob Clark, senior director for state government affairs at Medtronic, who attended Fridays meeting.
Before that meeting, the committee, created by a 2006 law that had bipartisan support, had ruled on 21 devices or procedures, rejecting coverage for about half of them, including arthroscopic knee surgery and calcium scoring for cardiac disease. Virtual colonoscopy was rejected explicitly because it cost more than conventional colonoscopy.
The other procedures, including routine ultrasound in pregnancy and hip resurfacing, were accepted, although the board set conditions on which type of patients would qualify.
The decisions made so far were expected to save the state $31.8 million annually, of several billions spent on health care. But at a time when the states Medicaid program has eliminated most vision and dental benefits for adults, every bit helps, program officials said.
Leah Hole-Curry, director of the program, defended its actions, saying they did not amount to rationing of health care.
Rationing is where you know you need something and without it you are going to suffer but theres not enough to go around, she offered as a definition. In this case, she said, the program denied coverage for procedures that have simply not been shown to work.
Its still pretty astounding that we have individuals who say we dont want you to look at scientific evidence in deciding how to spend taxpayer dollars, she said.
Until recently, at least, the program had not generated much controversy within the state. The decisions have been pretty balanced and we have not had a lot of apprehension among our members, said Dr. Dean Martz, president of the Washington State Medical Association, which represents 9,000 doctors. But Fridays meeting, held in a conference room one level above the ticket counters at Seattle-Tacoma International Airport, raised concerns among local and national medical experts.
First was a review of home blood glucose testing for children with insulin-dependent diabetes. An assessment of clinical trials prepared by a company called Spectrum Research the evidence vendor in the programs parlance found virtually no proof that testing more than five times a day improved health. But diabetes organizations and experts testified that this was because it would be unethical to do a trial in which some children were not allowed to test themselves frequently.
Dont mix up evidence-based medicine with ignorance-based medicine, Dr. Irl B. Hirsch, a professor at the University of Washington, who is a consultant for various companies, told the committee.
Melinda Woods said her 14-year-old son needed to check his glucose at meal times, snack times, when playing sports and in the middle of the night. Right there you are looking at seven or eight checks a day, she said.
The committee seven doctors, a nurse, a speech pathologist, a chiropractor and a naturopathic physician voted unanimously to cover finger prick tests with no daily limit. It voted to cover continuous glucose monitors mainly for children considered most at risk of a dangerous incident of low blood sugar.
The afternoon session on spinal cord injections was even more contentious. In the last few years, the Health Technology Assessment program has denied coverage to several pain-related procedures and devices, including spinal cord stimulation and pumps that deliver medication to the spinal cord.
Theyve basically decimated my practice, everything that I do that has value, said Dr. Arthur Watanabe, an interventional pain specialist in Spokane.
Spinal injections, usually of steroids or anesthetics, are commonly used by pain specialists. Indeed, even some doctors acknowledge the injections are overused to generate income, as has been pointed out by two reports in recent years from the Office of Inspector General of the Department of Health and Human Services. Washington State agencies spent about $15 million on the injections in 2009, at an average cost of $336 a procedure.
Pain specialists said denials of coverage for injections would force patients to use opioids or to undergo expensive back surgery, which is covered by the program. Eleven medical societies cooperated on comments opposing a denial of coverage, arguing, among other things, that other insurers covered many of the injections.
Experts from as far away as Australia testified at the meeting. About 30 patients, relatives and doctors, some lured by fliers placed in doctors waiting rooms, demonstrated outside the meeting room on Friday. But despite the big recruitment effort, only two patients who receive injections covered by the state program testified, one of which was Mr. Lamb.
The 299-page review by the evidence vendor found dozens of clinical trials of various types of spinal injections. Often, the trials did not show that the injections helped reduce pain or improve physical functioning compared with a placebo.
The pain specialists argued that clinical trials should not be the only criteria for coverage decisions. Published evidence does not exist in a vacuum but must be considered in a clinical context, Dr. Way Yin, a pain specialist from Bellingham, told the committee.
A big criticism made by the pain doctors, and also by the medical device companies, is that the committee lacks experts in the field being studied and therefore cannot judge the value of therapies. It did appear that most committee members were not familiar with the dizzying array of different spinal injections. Ms. Hole-Curry, the program director, asserted that having experts testify in public, rather than sit on the committee, was essential to avoiding undue influence from specialists and manufacturers.
Its very different from having a specialty group come in and say heres a report that supports our perspective, she said. In voting that dragged on until the early evening, the committee decided to cover some types of injections, with certain restrictions, and not to cover others.
Some coverage is better than no coverage, Dr. Yin said after the meeting. But the process, he said, can be improved.
