Congressional Pressure for Coverage of New Technology

As we debate the possible implementation of a government health plan, it’s good to take a deeper look at decision-making within the current federal health plan – Medicare.

The New England Journal this week
has an essay about the Medicare decision not to cover CT Colonography (an alternative to colonoscopy to screen for colon cancer.) The editorialists endorse the Centers for Medicare and Medicaid approach – pointing out that there are not good efficacy studies for the geriatric population. While the CT scan might be less odious for patients than a colonoscopy, a higher incidence of polyps in the elderly will lead to a higher rate of colonoscopies after CT colonography than in a younger population.

This reminds me of a case 5 years ago that was approached quite differently, which was reported very ably by the Washington Post. Harvard Link:

In this instance, there was scant evidence of efficacy of PET scans to diagnose early Alzheimer’s Disease, and the evidence that anti-Alzheimers medications helped delay clinical disease progression was marginal. The Medicare Coverage Advisory Committee recommended against coverage and the Alzheimers Association agreed based on its literature review. But CMS and the association both soon came under a full assault by lobbyists.

"We ran into a lot of people . . . who were obstacles," [the industry lobbyist] said…[and] "Guess what? They're all gone!”

Ted Stevens (yes, that Ted Stevens, who was senior Senator from Alaska and the Chair of the Senate Commerce Committee) threatened to hold up funding for CMS – and eventually CMS relented and provided coverage for PET scans for this questionable indication. That’s not an especially evidence-based method of determining insurance coverage!

The evidence for CT Colonography is improving every few months – so it might be that CMS should eventually approve this as a screening test for colon cancer. Ang its good news for evidence-based decision-making that Stevens is no longer in the Senate.

Let’s see how much pressure Congress exerts on CMS to reverse its appropriate decision not to cover this procedure yet. The example of offering coverage for PET scan for Alzheimer’s Disease demonstrates one of the potential weaknesses of a public plan. A public plan (and private plans too) should be insulated from this type of political pressure.