+++ Looking at the Cost of Healthcare

     While Congress, specifically the House of Representatives, continue to wrangle over funding the Patient Protection and Affordable Care Act (“Obamacare,” to use the pejorative), we here in the “Soviet of Washington”[1] have been quietly taking our own steps towards controlling health care costs. One such step was the establishment of the Washington Health Care Authority (HCA) in 2006. The stated purpose of the HCA is to ensure that the “most comprehensive health care options” are available through state-funded health care plans while “minimizing the financial burden which health care poses on the state.” RCW 41.05.006. The HCA selects different medical technologies for review by the Health Technology Clinical Committee (HTCC)—a panel of physicians and other health care professionals who determine whether those technologies will be covered by state-funded insurance programs.

 This complete and utter lack of oversight is troubling…

     Sounds like a laudable goal, doesn’t it? Unfortunately, in practice, the committee operates as an unaccountable cabal whose coverage decisions are not subject to any substantive review. When the legislature passed the bill creating the HCA and HTCC, it included a provision for appealing the HTCC’s coverage determinations. But Governor Gregoire vetoed that provision, ostensibly on the belief that other portions of the bill provided sufficient opportunity for review of HTCC coverage decisions. However, as the court of appeals has noted, “there is no statutory procedure for substantively challenging HTCC determinations.” Joy v. Dep’t of Labor & Indus.

     This complete and utter lack of oversight is troubling because the HTCC often makes decisions at odds not only with the medical community, but also most other insurance companies.

     Recently, the non-partisan Center for Public Integrity ran a story lauding the Washington HCA for “making the tough choice” to implement cost-cutting measures.[2] According to the story, “the Health Technology Assessment . . . reviewed three common, expensive and controversial treatments for chronic back pain: spinal injections, spinal stimulation, a transcutaneous electrical nerve stimulation.” That sentence needs a bit of unpacking. First of all, while relatively common, spinal injections are actually fairly inexpensive and generally considered conservative care. Conversely, while spinal stimulation is expensive, it is comparatively uncommon. But at its essence, the statement from this story is that these treatments are controversial. But are they? Let’s focus first on spinal cord stimulation, for which the HTCC denied coverage on the grounds that it is not safe, medically effective, or cost-effective.

     When the HTCC proposes a rule on the coverage or non-coverage of a given health technology, it submits that rule for public comment before publishing the final rule. When it published its findings to the public on spinal cord stimulation, medical practitioners from across the country submitted voluminous literature in support of coverage of spinal cord stimulation—not one medical provider commented that spinal cord stimulation was ineffective or unsafe. One commenter noted that spinal cord stimulation had been used safely and effectively since 1967 to treat intractable back pain without the use of addictive narcotics. The same commenter pointed out that Washington would be the only state to deny coverage of spinal cord stimulation, and that the vast majority of private insurers also cover the procedure.

     So why did Washington State decide not to cover spinal cord stimulation? According to the Center for Public Integrity, Josiah Morse, director of the Health Technology Assessment Program, says that the committee “downplays the role of cost in its decisions.” “[I]n most cases there isn’t enough research on the cost-effectiveness of medical technologies, so the committee makes most of its decisions based on safety and effectiveness.” But if no medical professional commented that spinal cord stimulation was unsafe or ineffective, why would the HTCC deny coverage?

     Consider another HTCC coverage decision—in 2011, it decided that femoroacetabular impingement (FAI) surgery was not covered. FAI is a condition involving the cartilage of the hip socket. It is extremely painful and, if left untreated, can result in the need for an early hip replacement. FAI surgery is the only solution for moderate to severe cases. The HTCC again requested public comments and again received overwhelming support for coverage of FAI surgery. In fact, the only comment not urging coverage came from Josiah Morse, who urged his own committee “to bullet, bold or otherwise call out the last sentence that no cost, cost-effectiveness data were found.” It seems inappropriate for Mr. Morse to emphasize a lack of data to his own committee as a reason to deny coverage of the surgery—especially when it is his committee that is entrusted to gather the data in the first place.

     The Washington Health Care Authority must be held accountable to the people of Washington State. Skyrocketing costs are obviously of great concern to anyone interested in healthcare reform, but costs alone cannot be the sole, or even dominant, ground upon which to base a healthcare benefit coverage determination. I, for one, am not comfortable living in a world where decisions about whether or not my insurance company will cover an expensive, life-saving or –altering procedure are based predominantly on the cost of the procedure.