Medical procedures rated by state's expert comparison shoppers

Interested in getting a CT "virtual" colonoscopy, touted as a more comfortable alternative to the common insert-and-probe test for colon cancer?

How about an upright MRI, which can take images of the body in multiple positions that horizontal MRIs can't?

If you are a state or public employee, on Medicaid or drawing workers' compensation, you can't have those procedures — at least not on the state's dime.

Since 2006, an obscure panel of 11 citizens has been serving as the state's scientific watchdog on medical issues. Its mission: Review clinical evidence on potentially questionable medical technologies and decide whether their track records and costs merit coverage by state agencies.

So far, the program, called Health Technology Assessment (HTA), has ruled against covering three procedures: the virtual colonoscopy; the upright MRI; and discography, a controversial diagnostic test for back pain. Two other procedures, pediatric bariatric (weight-loss) surgery and lumbar-fusion surgery for back pain, were approved — but with restrictions.

The rulings are binding for about 763,000 people in Washington. They include 177,000 public workers and their families who are covered by the Uniform Medical Plan; 446,000 people with fee-for-service Medicaid coverage; and 140,000 workers'-compensation claimants. In addition, state officials can opt to adopt the guidelines for veterans and prisoners.

HTA's work has pitted doctors against doctors and resulted in the state's most open confrontation yet over which medical advances are worth the cost. It also has turned Washington into a national trailblazer in embracing evidence-based medicine free of overt interference from political and economic interests.

"Washington's approach is: If there isn't reasonable proof that something is more beneficial than it is harmful, then they won't cover it," said Mark Gibson, deputy director of Center for Evidence-Based Policy at Oregon Health & Science University. In such cases, "withholding it isn't rationing. It's just good stewardship."

Tougher standards

Across the nation, a growing number of insurers, hospitals and others are applying scientific rigor to the inexact practice of medicine. The goal is to improve health outcomes and reduce waste by identifying and promoting the best standards of treatments. But that deliberative approach often gets upended by nonscientific factors. Such was the case last year when Medicare backed off its threat to deny coverage for controversial CT scans for the heart after lobbying by cardiologists.

But alone among all states, Washington has entrusted an 11-member independent citizens committee with binding authority to make coverage decisions. The committee acts, in effect, as unusually well-educated and -informed patients who — unlike most Americans — must pay for their health care directly out of pocket.

"If I were a patient and someone else was paying the bills, I wouldn't care how much treatments cost or how cost-effective they were," said Dr. Craig Blackmore, a Seattle radiologist and a member of the HTA clinical committee. "But there is a set amount of money to pay for health care" by public agencies.

Blackmore and his fellow committee members were chosen by the state for three-year terms from a field of 18 applicants. The group includes a heart surgeon, a nurse practitioner and a naturopathic physician. By law, the committee must include six doctors and five other health practitioners. Members meet at least quarterly and are paid just $150 an hour for the meetings, though they involve voluminous advance reading and preparation.

The committee currently has pending reviews of five treatments, among them arthroscopic knee surgery for osteoarthritis and implantable fusion pumps for painkillers for non-cancer patients.

The clinical committee's presumed scientific objectivity has made its rulings the focus of keen interest from other states, said Leah Hole-Curry, HTA's director. Coverage decisions made here, she said, may be adopted elsewhere.

"Everyone recognizes that the stakes are high" for the committee's actions, Hole-Curry said.

Back-surgery debate

Of HTA's five rulings so far, its decision to approve lumbar-fusion surgery for chronic low-back pain stirred the most heated debate. For more than a decade, Washington workers'-comp officials have amassed compelling numbers indicating that the operation is mostly a failure. Even two years after their surgery, two-thirds of injured workers remained disabled and off the job.

"We've had terrible outcomes with lumbar fusion in our system," said Dr. Gary Franklin, medical director for the Washington state Department of Labor & Industries, who co-wrote two studies analyzing his department's history with the operation.

But the HTA committee was not persuaded. It determined that overall scientific evidence showed that lumbar fusion worked as well as intensive rehabilitation and other treatments in reducing pain and disability. But the committee also made surgery a treatment of last resort by requiring the agencies to first pay for pain therapy and other alternatives.

Franklin said he accepts the decision, which potentially will make more injured workers eligible for fusion surgery. Previously, Labor and Industries covered it only for patients with measurable instability of the spine.

"I can't say I would have made the same decision," Franklin said. Nonetheless, he said, "I think it was a very intelligent decision."

Better outcomes

Above all, HTA focuses on measuring better health outcomes. Sometimes that can mean relying on a different yardstick from the one patients or their physicians might use.

Last August, for instance, HTA voted against covering gastric-bypass surgery for obese teens despite finding evidence that it helps people shed significant weight. The group was not convinced that the resulting weight loss automatically lowered such risk factors as high blood pressure and diabetes.

Though patients may be happy with their slimmer physiques, "losing a lot of weight if you aren't healthy isn't a good thing" from a public-health view, argued Dr. Brian Budenholzer, a family physician with Group Health Cooperative in Spokane who chairs HTA's clinical committee.

The committee also weighed the risks — including death — of gastric bypass and a second procedure, gastric banding. It looked at the combined costs, an average of $16,000 for the state, not counting pre- and post-surgery care. The committee ultimately issued a split vote: It approved gastric-banding surgery (which makes the stomach smaller) but not gastric bypass (which blocks absorption of food), and only for those who are at least 18.

When two competing technologies are similarly effective, the committee uses cost as a tiebreaker. That's what happened in the duel between computed tomographic, or virtual, colonoscopy and optical colonoscopy, long considered the gold standard for preventing cancer in the colon and the rectum. Committee members reviewed reams of scientific literature, as well as conflicting assertions submitted by proponents of both tests.

CT colonoscopy is performed by radiologists, while gastroenterologists do optical colonoscopies. CT-scanner manufacturers in particular criticized the committee for issuing a decision without waiting for final results of a definitive study they contend would demonstrate CT colonoscopy's virtues.

That prompted Dr. Amy Foxx-Orenstein, president of the American College of Gastroenterology, to retort that the debate was less about science than about turf.

"If I'm a foot doctor, I'm hoping you have a foot problem and not a shoulder problem," she said.

In the end, the committee's conclusion boiled down to this: Virtual colonoscopy may be about equally effective as traditional colonoscopies in detecting potentially cancerous polyps, although it's unclear whether that ultimately prevents more deaths from colon cancer.

But though some patients may find virtual colonoscopy to be more comfortable, at nearly $1,000 a pop it also is 25 percent more expensive. What's more, almost half of virtual-colonoscopy patients also undergo an optical colonoscopy in order to remove polyps that were found.

The evidence, Budenholzer said, favored the bottom line.

"When you go to the grocery store, you may want filet mignon, but you can't afford it," Budenholzer said. "At some point, we will have no choice but to look at health-care services and ask, 'Are they good value or not?' "

Kyung Song: 206-464-2423 or ksong@seattletimes.com