Former CMS Official “Admits” to Covert Rationing

July 16th, 2007 by DrRich

In his forthcoming book, Fixing American Healthcare - Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare, DrRich demonstrates how the imperative to covertly ration healthcare causes payers to bastardize evidence-based medicine. In a recent interview in Health Affairs, Sean Tunis MD, formerly Medical Director for the Centers for Medicare & Medicaid Services (CMS), goes a long way toward admitting this to be the case.

The case in point was a CMS coverage decision that was made in 2003 regarding the expanded usage of the implantable cardioverter defibrillator (ICD). The need for a coverage decision arose because a major randomized clinical trial (MADIT II) had been published demonstrating beyond reasonable doubt that patients with prior heart attacks and compromised cardiac function had significantly better survival if they received ICDs.

To make a long story short, despite incontrovertible scientific evidence that these patients would benefit from ICDs, despite the endorsement of the MADIT II results by professional organizations, despite the fact that most private insurers in the US had already expanded coverage to this new patient group, and despite the fact that CMS’ own advisory panel (hand picked by CMS) voted 7 -0 to expand coverage, CMS declined to do so. (Actually, they expanded coverage to some extent, but not to the extent supported by the evidence.) In making their non-coverage decision, CMS resorted to a particularly “interesting” form of statistical analysis that more objective observers recognized right away as statistical legerdemain.

In the recent Health Affairs interview, Dr. Tunis at last sheds some light into this decision. Cost, and not just scientific evidence, must be taken into account. He says,

“It was well understood by me and others at CMS that ICDs were expensive and that there were a lot of additional people who might be eligible for an ICD, and that added up to a large amount of money. So what does that cause us to do differently than for decisions with less potential financial impact? It causes us to look extremely carefully at data on safety and effectiveness. You might think of this as an upside-down or inside-out variation of a cost-effectiveness analysis in which the evidence threshold for coverage is implicitly adjusted based on a qualitative judgment about the economic impact of the decision.”

“In fact, explicit statements have been repeatedly made by Medicare that cost is not factor in coverage decision making. But my guess is that for anyone who works for a large payer in a policy environment that is increasingly panicked about the cost of health care, it’s easy to imagine how economic impacts could still have subtle and perhaps even unconscious effects on some of the scientific and value judgments that we have been talking about, whether or not these folks are told to ignore costs.”

Allow DrRich to interpret: Because CMS had to take cost into consideration, but at the same time because it is the explicit policy of CMS not to take cost into consideration, their only choice was to twist the science in such a way as to make the coverage decision they had to make because of cost considerations, while “blaming” the decision on the science.

To his credit, in the Health Affairs article Dr. Tunis explicitly decries this sort of covert healthcare rationing as obviously damaging and inefficient, and goes on to endorse a public discussion of rationing, with the aim of making it explicit and therefore less destructive. One suspects, on reading his comments, that a reason Dr. Tunis is no longer with CMS may be to avoid being repeatedly placed in the position of being an agent of covert rationing.

In any case, we see again in the ICD example an instance of the Fourth Corollary of the Grand Unification Theory of Healthcare: Covert rationing corrupts everything it touches. In this case, it corrupts the interpretation of medical science, and renders evidence-based medicine illigitimate. It is very difficult to trust evidence-based policy decisions when the “evidence” is being arbitrated by the payers - those who society has deputized to covertly ration our healthcare.

Posted in Wonkonian Rationing | 2 Comments »