‘Medicar’– shared decision making? part III

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Recently, my daughter asked my opinion of a salesperson’s suggestion that she spend extra for additional safety features on a new car she was buying. I recommended that the more safety features the better – after all it was her life that was at stake.

This led me to a stunning revelation. That unlike a car salesperson, when I work in my outpatient endovascular suite I don’t provide my patients with any information about added safety or long-term benefit of the devices in my armamentarium. Further, unlike car dealers who mark up prices for additional features, Medicare regulations oblige me to bear the cost of safer or more durable devices.

Imagine then a car-buying scenario similar to how my endosuite works. My daughter walks into the dealership and the salesperson, being a highly ethical chap, tells her that the base model costs $15,000 but the safest model has forward collision warning, a rear camera, and lane departure warnings; and it can even apply the brakes if it senses a collision. She asks him how much extra she needs to pay for these features, and is informed that according to government regulations under ‘Medicar’ he is not permitted to charge any extra. He will just throw them in at the base price!

Now I know most vascular surgeons would not like to be equated with car salespersons, but are we not also selling a product that may be improved by adding features that could be life or limb saving? For example a vascular surgeon might deploy a basic stent or a more expensive covered or drug-eluting stent. The premise is, of course, that these more costly stents offer a more durable result with less need for revisions which are associated with additional risk of complications. However, if we believe that is the case, is it not our obligation to advise the patient accordingly? More importantly is it not our obligation to actually use that device? But is it also our obligation to pay the premium? Rather, shouldn’t it have been reimbursed appropriately? And if not, why is it that we cannot offer the patient the option to purchase the improved stent just as if they were offered the opportunity to purchase an added safety feature for their new car? I am sure most would agree that many patients who could afford it would readily agree to pay for a stent that could limit the need for a repeat procedure. I am assured that this would be likely as the same restrictions do not apply in the pharmaceutical industry. Patients with cancer or another life-threatening condition often commit their entire savings to the cost of a new drug that may offer only a few months of extra life.

But in the convoluted system that we work in, Medicare and many insurance companies do not allow us to charge anything more than a predetermined amount usually based on the least expensive device. Until such time that a new device is definitively proven to be more efficacious, a process that usually takes many years, reimbursement will be so low as to make it financially unsustainable for physicians to use these devices in their outpatient facilities. The result is that patients remain uninformed, are left out of the decision-making process, and may be receiving an inferior product.

Inpatients may also be kept in the dark about alternative devices since hospital administrators may be making cost-saving decisions that limit various devices. Even if these devices are available hospital-employed vascular surgeons are encouraged to be cost conscious and to limit use of expensive items. Given these circumstances I doubt that many vascular surgeons discuss their technical choices with their patients.

I understand the rationale for government, insurance companies, and hospitals to limit paying for expensive and unproven equipment. But surely patients should be given the opportunity to be part of the discussion and, if they so desire, to pay for a novel device that they believe may provide a better outcome. Of course, that assumes that they have the financial ability to pay such a supplement. Further, there is the moral dilemma on servicing the indigent or those with limited funds? Must they “drive the base model” or be forced to “take the bus” as there is currently no alternative solution?

Clearly the system is flawed, and it is time for change. I have three proposals. Firstly, require Industry and CMS to speed up evaluation of new products and if they appear beneficial, but more costly, make sure that hospitals and endovascular centers are appropriately reimbursed for their use. Second, legislate that devices proven to be inferior can no longer be marketed except in special circumstances such as patients with limited life expectancy. It may be economically necessary for automobile manufacturers to build cars without expensive enhanced features. But even they must make some safety features available in their basic models. Surely medical equipment companies should be held to an even higher standard? Third, following on the automobile analogy, if patients are ultimately allowed to purchase a more expensive product, the government could levy a “Luxury Tax” just as they do with expensive gas-guzzler cars. These funds could be used to help offset the costs of providing more expensive devices for patients with limited means.

Until such time as these changes come about a physician should always use the devices that are most trustworthy despite financial constraints. Where appropriate we should educate patients as to the reasons that one device was selected over another. More importantly we should inform them as to why current reimbursement practices have excluded them from decisions that could potentially save their life or limbs. Change will occur only when our educated, concerned patients pressure their legislators and complain that current reimbursement practices are forcing them to travel the road to health in an unsafe vehicle.

Dr. Samson is a clinical professor of surgery (vascular) at Florida State University Medical School, is president, Mote Vascular Foundation, and is an attending vascular surgeon, Sarasota (Fla.) Vascular Specialists. Dr. Samson also considers himself a member of his proposed American College of Vascular Surgery.

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