FEATURE-HMOs seek 'evidence' in bid to stem costs


By Kim Dixon

CHICAGO, Aug 26 (Reuters) - Intel Corp. Chairman Andy Grove went on a mission a few years back to find the definitive treatment for his prostate cancer.

While Grove, whose illness is now in remission, was able to find a workable solution, he had to wade through a confusing maze of options in his search for treatment and coverage.

"There has never been a randomly controlled trial to say which treatment is best" for that type of cancer, said Humana's chief medical officer Jack Lord, recalling Grove's quest.

New technologies are said to be the main reason for driving employer health care costs higher and employers have responded by increasing deductibles and copayments.

"People may pay a different amount depending on how strong the evidence is for the treatment," Lord said.

HMOs, seeking to stem soaring medical inflation, see putting a stop to misuse or overuse of tests and drugs as a way to cut costs. More and more, insurers may demand concrete evidence before paying for treatments that aren't backed by rigorous scientific testing.

"As new information is emerging from the scientific community on what interventions are proven and what is insupportable, we are intensifying our actions," to make sure evidence drives coverage decisions, William McGuire, chief executive of UnitedHealth, told analysts recently.

For example, UnitedHealth data says 63 percent of cat scans and MRIs have not been indicated to be done. "There's a significant level of costs to be saved," company spokesman John Penshorn said.

At the center of the debate is an undeniable fact: Health care spending in the United States is set to double to $2.8 trillion by 2011, when it could reach 17 percent of the Gross National Product, according to government estimates.

SHOW ME PROOF The biggest selling point for drug and device companies is that new medicines and technology keep people out of the hospital and generally healthier for a longer period of time. New technologies are the single biggest factor driving up health care costs, experts say. Insurers are not suggesting that life-saving technology be set aside because of cost, but they are demanding proof the new products are effective.

The idea, so-called evidence-based medicine, posits that medical treatment is not always administered in a rigorous scientific manner, according to Robert Berenson, a health policy official during the Bill Clinton and Jimmy Carter administrations.

Doctors see limited numbers of patients and tend to provide care as they are used to, experts say. At the same time, doctors do not appreciate being told by health insurers how to practice medicine.

"It's pretty clear that physician autonomy is one major barrier" to health plans implementing the approach, Humana's Lord said.

Surgeons believe the best way to treat prostate cancer is surgery, radiologists think the best way is radiation, and so on, Lord said. "People believe in what they do."

Although the notion of evidence-based medicine isn't new, it has yet to be successfully implemented on a wide scale, experts say.

UnitedHealth has cut use in its top 6 diagnostic categories by zeroing in on the most expensive procedures and patients and managing their care accordingly, according to Roberta Goodman, an HMO analyst at Merrill Lynch.

"I don't think it's a silver bullet ... but I think it's one of the areas in the delivery of medicine that's just crying out for improvement," Goodman said recently.

Another barrier is America's seemingly voracious appetite for unlimited medical care, which some patients may assume equals better quality.

"The public has equated more care with better care," said Cigna chief medical officer Jeff Kang. "We actually know through this evidenced-based approach that this is not the fact."

Humana, for example, said it won't pay for AbioMed Inc.'s Abiocor artificial heart until there is more evidence that it's worth it. Of the seven patients who had the titanium and plastic heart implanted, only two are still living.


Manufacturers worry about all the talk about proof. They and doctors counter that medicine is an art, not always a science.

A device maker industry report recently weighed health plans' practice of assessing a new technology's impact before agreeing to pay for it.

It is dangerous to shift treatment decisions from doctors to those paying for care, who may not be qualified to make those decisions, they warned.

"The industry has a concern that evidence requirements could keep people from the treatments they need," said Carol Kelly, a vice president at AdvaMed, the main lobbying group for device companies such as Guidant Corp. and Johnson & Johnson in Washington D.C.

Employers, wary of escalating premiums also want to see quality before they pay for care. The Midwest Business Group on Health, which represents employers like Sears Roebuck & Co. and Ford Motor Co. , cites a high rate for bypass surgery patients. That, they say, may be related to overuse of tests administered, coupled with underuse of aspirin, among other possibly preventive treatments.

The group recently 'won' a 19 percent increase in premiums out of the health insurers they negotiate with in the Midwest. That was considered a victory because insurers had tried to charge up to 40 percent premium hikes.

Cigna's Kang said with all the competing financial interests in the delivery of healthcare, the idea of strictly adhering to evidence is the way to restore public faith in the system.

"Pharmaceutical or device manufacturers - they have the incentive to promote (their products) and managed care has the incentive to control the costs," so patients need objective measures to make smart choices, Kang said.



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