Health care cuts debated

The proven way to search for cancerous lumps in your lower intestine is to run a camera up there and have a look around.

It is not comfortable. Doctors run a long, thin black tube through the rectum and advance it through the upside-down “U” shape of the colon, guiding it around turns with a series of knobs on the end of the scope.

The idea of having a virtual colonoscopy, using X-rays to scan the colon, often is tempting to people who need the procedure, said Dr. Bruce Silverman, a gastroenterologist at Providence St. Peter Hospital in Olympia.

But Washington officials have decided against paying for virtual colonoscopies, part of the state’s drive to cut costs by denying coverage for treatments that officials decide offer little benefit for an added cost.

It’s an approach that has factored into the national debate about changing the health care system.

Paying only for evidence-based care could reduce costs. But limiting which treatments patients are entitled to also raises questions about government interfering with individual health needs.

The state Health Care Authority’s Heath Technology Assessment Program ruled against virtual colonoscopy after hearing from experts and the public and considering scientific research.

The decision affects hundreds of thousands of residents who use state medical programs, including public-employee health insurance, the Basic Health Program and Medicaid.

The colonoscopy decision saves the state $11 million in health costs each year, according to the state agency.

DECIDING WHAT WORKS

In the case of the virtual colonoscopy, the benefits don’t outweigh the cost, said Silverman, who agrees with the state decision.

He volunteered for a virtual colonoscopy once and has performed 10,000 standard procedures, he said.

Virtual colonoscopies don’t require heavy sedation, but they do require patients to take laxatives. A virtual colonoscopy also requires inflating the bowel with air for better scanning.

The virtual colonoscopies don’t find the smallest polyps as easily, Silverman said, and if a lump is found with a scan, it still has to be removed the old-fashioned way.

In 95 percent of cases, that means a standard colonoscopy: snaking the colonoscope through the intestine, then lassoing the polyp with a wire. The wire is hooked to an electrical charge, cutting off the lump and cauterizing the wound.

“It allows the physician to look inside, to look for sizeable – or less than sizable – anomalies. And as part of it, an anomaly that is found … can be removed safely without delay,” Silverman said.

The virtual procedure is just as safe as a standard colonoscopy, and just as effective in finding problems, the Health Technology Assessment Program decided last year. But it decided against paying for them, based on their costs.

They are more expensive, and if they do uncover a concern, they require a second, standard colonoscopy, the program’s panel of experts said.

Program officials have considered nine other high-tech procedures, blocking payment for four of them. The agency says the program has saved $27 million since 2007.

EXPANDED ELSEWHERE

The state has applied similar evidence-based approaches to other areas of medicine, notably in prescription drugs.

Asking pharmacists to fill prescriptions from a list of preferred, low-cost medicines has saved money, including about $37 million in the first two years, according to a recent legislative audit.

The preferred-drug list established by the state in 2004 steers pharmacists away from pricey name-brand drugs and toward generics or cheaper alternatives.

“It says that they are all equally effective, they are all equally safe, and therefore they can all be therapeutic across the drug class,” said Dr. Jeffery Thompson, medical director at the state Health and Recovery Services Administration.

Looking to save money this year, the Legislature approved a more aggressive plan, telling the state to contact physicians who prescribe an unusually high number of name-brand drugs.

“We’re on the hook for roughly about $80 million,” Thompson said.

The Washington State Medical Association, which represents doctors, supported the plan.

The association president, Dr. Cynthia Markus, noted that private insurance plans also push for lower-cost drugs.

“They can tell you we won’t cover certain brand names, we only cover generic jobs,” she noted. “That’s part of the contract, and when you go to the pharmacy, you find that out.”

A ROLE FOR PATIENTS

When it comes to the drug list or approving new technological treatments, the government decides what patients can receive – unless they want to pay out of pocket.

But a different, first-of-its-kind program gives patients the choice.

Called shared decision making, the process gives patients access to independent information, such as a DVD discussing research on the effectiveness of using a tiny tube to hold open blocked arteries.

Championed in 2007 by Sen. Cheryl Pflug, a nurse, the idea is that patients will choose less-costly treatment if they know the latest treatment hasn’t proved to be any better.