Containing the runaway costs of medical care is perhaps the thorniest of health care issues. Despite the rhetoric about getting medical spending under control, agreement on that point may not be universal. The health reform law calls for tepid cost containment measures, yet the long-knives of the special interests are ready to gut them while whetting the public’s appetite for more expensive technology. It’s a complicated, charged, and crucial issue: the press needs to dig in and own it. This is the fourth in a periodic series of posts that will scrutinize how well the press does that. The entire series is archived here.
A laurel goes to the Center for Public Integrity for its intriguing tale of ever-climbing health care costs and the monied interests that propel them beyond the clouds. In a report called Manipulating Medicare, the Center, along with some help from the Public Insight Network, methodically dissected how digital mammography came to be and how its journey is but another example of medical technology’s role in the uncontrollable costs that threaten to kill Medicare as we know it.
The Center’s story shows how makers of digital imaging equipment—GE et al—managed to use clever marketing, public relations, and campaign contributions to transform digital mammography into almost the standard of care for women undergoing breast exams. What makes this all the more remarkable, the Center says, is that the scientific evidence to date shows the “newer technology has not been proven to improve breast cancer detection, particularly among women 65 and older.”
I had a sense of déjà vu reading the piece. Ten years ago, I wrote a piece for CJR, “Covering Medical Technology—The Seven Deadly Sins.” The story included a sidebar about new technology for Pap smears, which cost a lot more than the conventional technology at the time but followed a similar path as digital mammography to commercial legitimacy. Along the way, costs for Pap smears zoomed up. The Center’s story sets the context for its mammography findings by noting the marketing triumph of that Pap smear technology, estimating that it cost Medicare an extra $90 million and was no better at finding cancer.
A five-year trial sponsored by the National Cancer Institute, released in 2005, suggests that digital mammography finds no more cancers in older women than film mammograms. The Center reported, however, that “the lack of evidence that digital mammography benefits women over 65 has not kept radiologists from using it to screen Medicare patients.” Apparently, radiologists use it even though the U.S. Preventive Services Task Force says there is insufficient evidence to assess the benefits or harms of digital mammography, regardless of a women’s age.
The Center, along with The Wall Street Journal, analyzed a six-year sample of Medicare billing data, revealing that digital mammograms had pretty much replaced standard film mammography. In 2003, film mammograms accounted for 96 percent of all mammography claims. By 2008, film studies made up 47 percent of the claims. “Over time, film mammography is going to cease to exist,” Anna Tosteson, the lead researcher on the major clinical trial, told the Center. “But here is one thing that’s certain—there is no evidence that one should pay a premium for digital mammography.”
But that’s just what Medicare is doing, and the agency’s role makes the Center’s story fascinating reading. It causes readers to wonder if Medicare is for real when they learn that the Center’s analysis shows that digital mammography may have boosted the cost of breast cancer screening by more than $350 million from 2003 to 2008. Medicare has been reimbursing doctors $129 for each digital mammogram, compared to $78 for films—a 62 percent increase. That helps explain why radiology practices are ecstatic about the new machines. When Oregon Imaging Centers went digital, it saw a 22 percent increase in patient volume and more bucks for increased imaging and diagnostic procedures, such as MRIs, ultrasound, and biopsies.
Medicare says its hands are tied. Once the agency determines that it will pay for something—the political shenanigans about payment for digital machines are woven into the story—officials do not have the authority to set prices the agency will pay based on the comparative effectiveness of the competing technologies. It pays according to the resources required to perform the tests, and the resources for digital mammography are much higher than for film studies largely because the machines are expensive to buy and maintain. That high cost, of course, benefits the all-powerful manufacturers, which can influence Congress to keep the prices high.
But what about the health reform law? The Center briefly mentioned the deal here: the law forbids Medicare from using the data from comparative effectiveness studies in setting reimbursements. That notion died early in the debate. It’s not hard to figure out who was behind that. If the Center’s story revives a debate over cost effectiveness, that could be its real achievement.
It should also serve as a model for other news outlets to investigate questionable and costly technologies—and, more important, link them to the future of Medicare. Most Medicare beneficiaries don’t know that digital mammography is directly related to their Medicare benefits, which one day may disappear. One woman who just signed up for Medicare told the Center she had more confidence in the recommendations of radiologists then researchers and epidemiologists. “They know what is easier to look at,” she said.