POLL: Who should pay the cost of an “elective” procedure?

Men diagnosed with favorable risk prostate cancer are recommended for Active Surveillance (AS). AS is a method of safely monitoring one’s conditions for possible progression to the stage at which an aggressive intervention becomes the new recommendation.

Low-risk men on AS are at the same risk level for progression or mortality as similarly classified men who pursue immediate aggressive treatment, but over the long term half or more of men on AS never need aggressive treatment. Moreover, men who do pursue immediate aggressive treatment for low-risk PC often subject themselves to a lower quality of life due to side effects, and/or other secondary medical procedures seeking to correct unfavorable primary PC treatment outcomes, while experiencing no prostate cancer-specific benefit.

The uptake of AS in the U.S. is now approaching 50% of eligible men, but that means 50% are pursue medically unnecessary, immediate aggressive treatments (most commonly surgery, or radiation therapy). Today, Medicare or private insurance provides high reimbursement coverage for aggressive PC treatments, even in the cases described here as medically unnecessary.

Under current regulations, if Medicare pays for an unnecessary procedure, every tax-paying American contributes additional tax revenue for that event. If private insurance pays for an unnecessary procedure, then again “we” collectively (although not so uniformly as through taxes) pay through greater wage reduction for higher insurance premiums.

A 2015 article in the New Yorker titled “Overkill http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande” (and numerous other recent similar articles) highlighted that millions of Americans get tests, drugs, and operations that won’t make them better, may cause harm, and cost billions…low-risk prostate cancer was amongst the specific illnesses discussed. Other medical articles have estimated that the cost of PC overtreatment alone is more than $1 billion per year in the U.S. At 17% of GDP and growing, the U.S. healthcare system is (by far) the most expensive in the world (and ranked 11th globally in quality of care). LINK http://www.pbs.org/newshour/rundown/health-costs-how-the-us-compares-with-other-countries/ Naturally, challenging questions are being asked about overspending, and low-risk prostate cancer overtreatment is increasingly being discussed as a candidate for reduced spending.

So, how do you feel about paying for large numbers of “elective” procedures? Should Medicare/insurance coverage be reduced or eliminated for unnecessary medical treatments? Should we continue without changes?

Discuss merits

Gemlin said...
Interesting figures. Wouldn't you expect correlation between health expenditure per capita and average life expectancy?

Yes, generally, assuming all other factors being equal. Many would postulate that the U.S. healthcare system is "broken." (Google: "US healthcare broken", many results) But life expectancy is a different topic.

Gemlin said...
Overtreatment of clinical insignificant PCa is not the reason for shorter life in US (only to the higher cost).

Agreed. Life expectancy is a different topic than this post/poll.

JNF, you may be right that the scenario in the poll may be more commonly described as "unnecessary" rather than "elective." Particularly if you are splitting hairs with the insurance industry...the better term is "unnecessary." But, I think that the detailed discussion in the original post makes it quite clear, and others here at HW/PC have used the term "elective" interchangeably, albeit incorrectly, with "medically unnecessary" in this same context. Thanks for pointing this out, nonetheless.

My first thought is that this is way too complicated a question for me to be weighing in when I just peaked at the website as a way to procrastinate my work. So I'll just make a quick remark(s)...

I'm an advocate of Active Surveillance. But many men with favorable risk prostate cancer actually are recommended to have treatment, not go on AS. If I had to guess, I'd say the vast majority are. To that end, it would be nice if the medical professionals were leading the way on this, not just the folks that pay the bills.

And it's a delicate thing to take choice away from patients. A frequent comment here is that some folks just aren't cut out for Active Surveillance and I have to say I get that. Should those folks have no choice?

It's a complicated issue and I'd really like to see more guys choose AS, but given our current medical landscape, I'd say "treatment should still be covered by insurance."

I do not think that piecmeal fixes, such as elimimating procedures the New Yorker feels are unnecessary, will fix our bankrupt medical system. My experience in the past is that well intentioned changes are promised to cost less ... but end up costing more.

If we want to get our medical expenditures down to the level of the rest of the industrialized world (10% of GDP range versus 20% range) we should emulate the health care systems in the other industrialized countries.

I do not think I can mention what this would entail as it would cause a lock to be placed on this thread. Indeed, I am surprised we can discuss any changes to the existing system, without it being looked at as political.

Tudpock18 said...
Although I think I read and understood Jack's point, I think JNF's clarification was helpful.

...

Given that this could become an incendiary or political topic I will also just make a preemptive request for civility.

Jim

I found one of your posts, Jim, from 2010 which also indicated that you would have understood the original point (using the term "elective"). You wrote: "However, if I was the Medicare Czar or King of Health Care Cost Reduction, I must admit I would be tempted to determine that some treatment plans for "very low risk" PCa diagnoses would be treated as elective rather than automatically paid."
https://www.healingwell.com/community/default.aspx?f=35&m=1892989&p=2

At least you've remained consistent over the years!

I will also make an effort to steer anyone who gets goofy and off-course back to the non-political topic at-hand.

thanks!



added later as edit: I believe Purgatory's proposal was to not allow (ie. prohibit) aggressive treatment of low-risk cases; this is somewhat different, as described above to RCS.

Post Edited (JackH) : 1/27/2016 3:31:07 PM (GMT-7)

Jack,
To eliminate unnessecary procedures, including unnessecary PCa treatment, the federal government would need to set up a board to make sure all state programs follow the new regulations (I assume this would be an unfunded mandate for the states), not to mention the suits that guys/families would file because their G6 turned out to be a G7 after the autopsy, and .... you can see where I am going with this.

Let the system be what it is or "change it" .... tweeks only add costs.

Post Edited (RCS) : 1/27/2016 3:18:56 PM (GMT-7)

Hard question. Personally I want to have my individual choice, but 17% of GDP with out any major increases in medical outcomes is not sustainable. We will end up with some type of rationing, either by the govt or the insurance industry.
Try to find a doctor today that accepts new Medicare patients, I went through 12 before I found one, and the time to get a normal appointment has gone from a week to a month.

Jack,

It's a magical thing, that ritual that makes an ordinary member into a moderator -- the robes, the incense, the chanting, the rubber mallet, and the liberating feeling of all of one's political opinions falling away...

It's a little bit unfair to quote back to moderators things we might have posted years ago in our larval form, since we can neither agree, disagree, nor clarify.

PeterDisAbelard. said...
...

It's a little bit unfair to quote back to moderators things we might have posted years ago in our larval form, since we can neither agree, disagree, nor clarify.

Uh, Peter, there are worse things to be accused of than being consistent.


Moreover, the 2010 post I referenced had Jim labeled as "forum moderator." That's the "what." There are probably several good ways of "how" you could fix that, but that's a topic for another thread.

Jack,

I'm afraid the "Forum Moderator" in the left hand column is an unreliable guide to whether the author of an older comment was a moderator at the time he posted it. Here's a link to one of my first posts:

Hormone Therapy, the Pod Person and the Plan

If you glance at it you will notice that I am identified as a moderator. You might be tempted to suppose that I emerged on the forum as a moderator, fully formed like Athena bursting from the forehead of Zeus, but that is not the case.

Just for fun, I looked up the definitions of 'elective' and 'medical necessity': To summarize:

"elective" when it comes to medical treatment refers to treatment that is scheduled in advance as opposed to immediate or emergency. So, for all of us here, our PC treatment was elective in nature. We scheduled and planned it. Someone who goes in for a colonoscopy and winds up in the OR a few hours later because they found a blockage is not having elective surgery.

"medical necessity" is a term that revolves around the peer-reviewed and accepted standard of care for a particular condition or illness. So, either surgery or radiation falls under the definition of medical necessity for a diagnosis of prostate cancer. However, new treatments or new drugs may NOT, if they are still considered experimental.

This is quite different from the common lay definitions. We'd like to say that elective is about (for example) pure cosmetic surgery such as breast implants for 22 year olds who don't like their B cups and would prefer a D. Or Ms. Jolie's surgery. Or, perhaps, aggressive treatment for low-risk PC--which is what this OP is about.

I don't think, in general, that the American medical consuming public is ever going to accept a "book" that defines a single acceptable treatment for any given condition. Plus, I, for one, (and many others, I suspect), have a serious issue with saying "if you want treatment, you have to pay for it out of pocket because it's not 'in the book'" This has the practical effect of defining the standard of care for a particular patient based on their ability to pay for it--which raises all kinds of ethical problems. It's all about whether (here's an almost political statement) health care and medical treatment are a human right or whether it's a matter of privilege based on economic status.

Sheepguy,

Very good point on the testing. Someone has to make the tough decision on when to stop treatment/testing. From what I have observed, currently (in the USA) it does not appear to be the doctor or the patient, especially if it is a "covered" procedure. The decision is left up to the insurance company/Medicare to wear the black hat. Thus JackH's poll to determine how to change Medicare regulations for PCa treatment.

Halbert,

I feel we currently have a book(s) saying what is covered and what is not covered. The books are our insurance contracts or Medicare coverage guidelines. Again, I think this is the point of JackHs poll, to propose ideas on how to change Medicare/insurance coverage for PCa treatment in order to lower USA medical cost.