Thursday, March 28, 2013

Doctors as Purchasing Agents

Thanks to NPR, I was directed to an op-ed that appeared in the New York Times in October 2012 entitled "In Cancer Care, Cost Matters."  The article describes what may be one of the earliest accounts where doctors at Sloan-Kettering decided not to use a new cancer drug because of its extra cost when they were already using equally-effective drugs for their cancer treatments.  The article piqued my interest.  These days for any doctor who uses expensive technologies, it is easy to see where this evaluation will lead us in our new era of cost concerns in medicine.  Medical device companies should take notice.

Few use more expensive technology in medicine than cardiologists and cardiac electrophysiologists.  Not only is our technology expensive, it is also used frequently.  Cardiovascular disease remains one of the largest cost drivers in medicine.

In the past, doctors (myself included) were complicit with device companies in our use of new technologies, implanting the latest model of defibrillator, for instance, not because it saved lives any better, but more so we could boast that our patients were receiving a "Cadillac" defibrillator rather than a "Ford" device (no disrespect intended to car companies, but you get my drift).  After all, our patients deserved the best and most innovative technology available at the time.  We did not want to be caught in the embarrassing position of being behind innovation power curve either.

I should acknowledge that there have been some very important recent developments with defibrillators since the 2005-2006 device recalls that plagued our specialty.  The ability to monitor device reliability wirelessly facilitated the ability to detect device battery depletions or lead failures and has improved our understanding of tolerable device and lead failure rates, for instance.  But it is not uncommon for a newly-named pacemaker or defibrillator to add several thousand dollars to the health care system over last year's device yet they may add only minor advances over the prior year's model.

Pacemakers, too, are being manufactured that are FDA-labelled "MRI-tolerant."  But examples of safe application of MRI's to conventional pacemakers are prevalent in the medical literature, so is the extra cost of an MRI-safe pacemaker worth it?  (In actuality, if you ask the informed pacemaker implanters out there, the main reason MRI pacemakers are routinely implanted is not because of safety concerns, but because of the CMS coverage decision for MRI payment in patients with pacemakers.(pdf))  How do we weigh the cost of these extra advances in technology versus their ability to improve our patients' actual morbidity and mortality?

Increasingly, doctors will soon be involved with purchasing decisions for advanced technologies.  Pacemakers, defibrillators, implantable monitors, stents, catheters, and even small sheaths will be scrutinized for their utility, ease of use, and cost.  (The liability of NOT using a technology will also be considered, but this issue is hard to measure and  less familiar to frontline doctors.)

The real question, of course, is will the patient see these cost savings if older technologies are used?  This is hard to say since there are so many layers to our health care system between the patient and the dollar.    Also, how will patients react when they find out online that their model of medical device is last year's model rather than this year's?  Will they seek another hospital system with shinier walls and bigger names?  It's impossible to tell.

But if hospitals are smart, they'll make it clear to the patient on their bill what they saved themselves by using an earlier-year device.  Medical device companies, too, might shift their marketing tactics to costs and benefits from things like size or shape of their device.  

But one thing's for certain in the days ahead: device companies will have to carry not just this year's model of device, but last year's, too.  Innovations in technologies will be harder to sell unless they show real patient morbidity or mortality benefit.  Companies will have to adapt their marketing campaigns since cost savings, done correctly, will benefit everyone.

After all, it's now about real costs and benefits in health care, rather than just sexy bells and whistles.


Addendum: The CMS National Coverage Decision for MRIs in patients with pacemakers is now functional.


Anonymous said...

Even with those caveats I'd rather have you as a physician making those tradeoffs then an administrative purchasing agent who doesn't understand the clinical implications. And at least in our area we are getting pacemaker and ICD prices to decline 2-3% a year even with new models.

Anonymous said...

The Cadillac vs Ford analogy can go far in health care.

Last year I pulled up to the new cardiac wing of our local hospital and found they had complementary valet parking. That's when I knew hospitals have jumped the shark.

We're in small city in a rural county, where land is cheap and valet parking is unheard of. I'm not sure I can name another place in town with valet parking, at any price.

We live Ford lives, happily. We earn a middle class living and support the local college sports teams where you can still find a $10 ticket. Our city argues about raising trash fees by $2 because it makes a difference to the people who live here. There are people who drive luxury cars around, but they didn't buy them around here. There are no luxury car dealers.

The hospital is the only place in town where luxury abounds. It's not our personality and it's not our style, especially considering the price tag. 2nd run movies are fine with us, and last years pacemaker if Ok too.

and I'll be darned if I'm letting some young kid drive off to park MY truck. No way he puts the seat back where I like it.

Anonymous said...

At last we are talking about price! For all your unhappiness about Obamacare, I am hopeful that you see this as a good thing. And I'm another patient who is just fine with a Ford.

medicine for real said...

Try reading the two articles about robotic surgery, one in the New York Times and one in the Boston Globe. Any time there is an industry rep in the room, someone is being sold something.

Anonymous said...

The CMS coverage etc link is broken but I'd love to read it

DrWes said...

Anony 11:09PM -
The link is now functional (the pdf file is rather lengthy, however).

In case you need it to paste into your browser, here's the link: