Kudos to Christopher Snowbeck and the Pioneer Press for digging into new Medicare data to report that the state the newspaper serves is out of whack with the rest of the country in how many expensive MRI scans are done on Minnesotans' bad backs.

Snowbeck artfully captures the predictable rationalization and defensive responses coming from locals who don't like what the data suggest. Because what they suggest is overuse leading to overtreatment. So here's one attempt a provider makes to deflect the data:

"The Medicare billing/claims data, which this report is generated from, would not capture conversations between a patient and provider that may have addressed alternative therapies for lower back pain," said Robert Prevost, a spokesman for North Memorial Health Care. "It's important to recognize the limitations of this data."

No, data don't capture conversations. But wouldn't it be fascinating to be a fly on the wall during those many patient-physician encounters that led to an MRI to see what level of truly informed shared decision-making (if any) took place?

The story includes other excuses from local providers along the lines of "the data are outdated...we've changed...we're better now...that can't be right...it's not us!" When have you ever seen a story on health care data that didn't have these predictable reactions? It reminds me of The Tobacco Institute continually rejecting any new finding that showed new harms from smoking. When you don't like the data, damn the data. For most of the history of medicine we had no outcomes data to show patterns of practice or what happens to people over time. Now that we're starting to collect some such data, vested interests find that information is a menacing thing.

Instead, we can learn from it, even if it is a little surprising or embarrassing.

The story captured a key question about "what's the right rate of MRIs?" Excerpt:

" (a) spokeswoman for the Minnesota Hospital Association (said) "It is impossible to make judgments from the data ... on whether or not clinicians ordered too many, too few or just the right number of imaging tests."

Bingo. And that's why the data are important whether you live in a high-use or low-use area. As Dartmouth's Jack Wennberg has been saying for decades, we don't know the right rate of utilization of many medical interventions. But the variations across the country show that patients may not be fully informed, may not be told about the tradeoffs of benefits and harms, and may not be provided a truly shared decision-making encounter. Until true reform occurs in these patient-physician encounters, you can forget about getting overuse, overtreatment and health care spending under control.

Snowbeck and the Pioneer Press did a good job of digging and finding an important local story.

And where was the much larger, much better-staffed Star Tribune on this story? The same paper that just stole away Snowbeck's colleague Jeremy Olson who used to cover health care for the Pioneer Press? Deafeningly silent. I had actually written to a key staffer at the Star Tribune recently asking when/if the state's biggest paper was going to mine the data from the new Medicare database to see if there were any important local findings. I got no response. I've not seen a story in the paper on it. And I couldn't find one after I did an online search. Maybe I missed it. But regardless, thank goodness for a little remaining competition between two newspapers in a metropolitan area. And on this one - apparently - the little guy won the day big time.

Reuters reports on a study in the current Archives of Internal Medicine that shows that:

"...after the U.S. Congress had mandated Medicare coverage of a digital tool to help detect breast cancer, health providers were quick to pick it up even though it hadn't showed clear-cut benefits for the women.

The technology, known as computer-aided detection, costs more than $100,000 to install, according to the researchers...

"It illustrates a bigger problem that exists in our society, where the rails are really greased to get new technologies into practice before we are sure that they are safe," Dr. Joshua J. Fenton, who led the study, told Reuters Health.

"There is no evidence that the use of computer-aided detection reduces breast cancer mortality," he added.

A commentary by Dr. Karla Kerlikowski in the same journal calls for "evidence of benefits outweighing harms before implementing new technologies." Excerpt:

Why do new technologies get disseminated so quickly when evidence is incomplete and/or conflicting? One explanation is that the focus of evaluating new diagnostic tests is on providing evidence to support improved or at least equal benefit of the technology with much less attention to the potential harms of new technologies prior to dissemination. In other words, the benefit of the new technology compared with existing technologies is examined but not necessarily whether the potential benefit of the new technology outweighs the harms of the test. In addition, the designs of comparative studies are often maximized to measure the added benefit of the test to detect disease compared with standard tests rather than assessing effectiveness in community practice on important clinical outcomes. Lastly, there are several forces that may encourage the rapid adoption of new technologies, including investigators with professional interests, technology companies with financial investments, lobbyists with vested interests, and a public convinced that new advanced technology is always better.
...
Health care providers and individuals cannot presume that newer technologies are better than existing ones without actual data to that effect. Health care providers should not adopt new technologies without first demanding scientific evidence beyond that required for FDA approval. They need to ask how strong and consistent is the evidence for new technologies and whether the evidence shows an important clinical benefit, whether there are important harms, and whether the benefits outweigh the harms. To be responsible advocates for high-quality medical care, our enthusiasm for new technologies should not replace strong, consistent evidence that the benefits of the new technology outweigh the harms in a clinically important way.

Finally, in another commentary in the journal, this one by Dr. George Sawaya on the attempt to reduce harms of cervical cancer screening "by setting appropriate lower and upper age limits for screening and avoiding too-frequent testing among average- and low-risk individuals," harms are another key focus:

To move forward, clinicians and patients must first be more cognizant of screening harms in all its forms, and studies must be designed to measure not only the likelihood of benefit with various screening strategies but also the likelihood of harm. Second, comprehensive and integrative methods must be identified and used to determine an appropriate balance between benefits and harms that seems reasonable to a variety of stakeholders. Finally, the rationale behind screening guidelines designed to maximize benefits and minimize harms must be clearly communicated to everyone.

While the "less is more" argument may never be convincing to many stakeholders in cancer screening, its rationale should resonate with many clinicians steeped in the tradition of doing no harm.

This AP story raises many important questions about the quality of information consumers receive (or not) about the quality of care. Excerpt:

"Millions of seniors signed up for popular Medicare Advantage insurance plans don't get the best quality, an independent study found.
...
The analysis found that 47 percent of Medicare beneficiaries are in plans that rate three stars or two -- medium to fair quality. Just 23 percent were signed up in plans that rate four or five stars -- very good to excellent quality. Many of the rest were in plans not yet rated."

Are consumers not aware of the ratings?
Not receiving them?
Not understanding them?
Not trusting them?

These are important questions for journalists to investigate.

In any talk I give to journalists, I encourage them to look into the proliferation of proton beam facilities for cancer therapy. Few have done so with any zeal.

• The New York Times did a good job.

• The Columbus Dispatch did not.

Journalist Merrill Goozner gives ample food for thought in an article in the Journal of the National Cancer Institute, "The Proton Beam Debate: Are Facilities Outstripping the Evidence?" (subscription required for full access). Excerpt:

"A recent report from the Agency for Healthcare Research and Quality (AHRQ) found no evidence to support claims that cancer patients undergoing pricey proton beam radiation therapy (PRT) achieve better outcomes or experience fewer side effects than patients receiving traditional photon radiation.

In the report's wake, proton therapy practitioners are pushing for the first trial comparing the two approaches for prostate cancer, which is the fastest growing use of PRT. The hope for PRT is that it will cause less collateral damage to surrounding nerves and tissue than intensity-modulated radiation therapy (IMRT), the most advanced form of traditional photon radiation.

"It hasn't proven itself to be superior," said Anthony L. Zietman, M.D., professor of radiation oncology at Harvard Medical School in Boston, whose affiliated Massachusetts General Hospital runs one of seven operating proton beam cancer treatment centers in the U.S. "We've applied for a comparative-effectiveness grant to do a head-to-head trial with IMRT with the same radiation dose," he said. The primary endpoint is quality of life.

Even if funded, it will be years before the results of such a trial are known. With dozens of facilities already built or in development worldwide, use of the technology and the controversy surrounding it are bound to grow. In the U.S., where at least three new $100 million-plus proton beam facilities are either under construction or in the planning stage, the costly treatment could dramatically increase Medicare spending on prostate cancer care alone."

WBBM in Chicago last week asked, "Is Medicare Ignoring Cheaper Lung Cancer Test?"

In its report, the TV station's "investigator" team promoted a company president's complaints against Medicare for much of the piece. They let him get away with saying:

"This is a potentially very powerful tool in the toolbox against lung cancer. You can zap the cancer and potentially be cured of early-stage lung cancer without ever having the surgery."

Should we be hearing that from a company president worried about his bottom line while he "wows" the audience with blown-up images like the one at left that appeared in the story? Or should we hear about evidence and data from an independent investigator whose research could speak to efficacy? The story never provided any data to back up the company president's self-interested claims.

They also let him get away with saying, "I think it has the potential to save Medicare millions of dollars."

We're not getting much smarter from stories like this. We're sure not getting a better understanding that in health care, "more is not always better and newer is not always better." We're also not being shown how often special interests - Pharma, device makers, specialty physician groups, etc. - are digging in against health care reform.

Recently, Trudy Lieberman wrote in the Columbia Journalism Review about how cardiologists were using journalists to complain about their reimbursement levels being cut by Medicare. She wrote:

"The doctors' letter warned that they "will be either forced out of business or forced to drastically increase the number of patients seen, most likely with physician assistants or nurse practitioners." Oh, oh. The specter of rationing and inferior care--"

See the similar themes in what she wrote about and in what we saw in the Chicago WBBM story?

Lieberman praised a Miami Herald story for how it handled the issue but said that:

"..a bunch of news articles for the most part passed along the cardiologists' complaints, threats, and warnings without any hint that there was another side to the story. Between the slanted newspaper articles and audio news releases from the American College of Cardiology, millions of Americans learned that the incomes of heart doctors, which can be upwards of $400,000, could take a hit. As an example of the kinds of cuts Medicare envisioned under the new rule, the administrator of one Florida heart practice explained that the reimbursement for a nuclear stress test could drop from $850 to $600. Presumably he said it with a straight face."

News stories that foster rhetoric and fear-mongering aren't making us any smarter. As Lieberman wrote:

"Containing the runaway cost of medical care is the thorniest of all the thorny issues in the health-reform debate. It is a complicated, charged, and crucial issue; the press needs to dig in and own it."

In another fine example of its dedication to important health care journalism, the Milwaukee Journal-Sentinel published a piece, "Debate on MRI payments just one hurdle for reform."

Gems in this piece include:

• Information on the Access to Medical Imaging Coalition, a group backed by the major manufacturers of imaging equipment, including GE Healthcare. The paper reports: "That industry backing goes unmentioned by the innocuously named group. The Access to Medical Imaging Coalition, which includes cardiologists and radiologists, is just one of the myriad special interest groups that often oppose cuts in what Medicare pays for medical services."

• "The reality is the status quo puts a lot of money in a lot of people's pockets," said Alwyn Cassil, a spokeswoman for the Center for Studying Health System Change, a policy research organization in Washington, D.C.

  Another reality is groups such as the Access to Medical Imaging Coalition often succeed in persuading Congress to protect their interests.

Read the entire piece. It includes local angles on local industry affected and about Wisconsin legislators' activities in this area. A fine example of local journalism on a national issue.

That quote comes from a Minnesota physician in a Pioneer Press article that includes many good elements:

• Info on disparities in Medicare spending;


• Dartmouth Atlas data and graphic;


• Local angle on Atul Gawande's New Yorker piece .

Kudos to reporter Jeremy Olson.

Newer is not always better. Evidence is important. Simple themes, oft forgotten in health journalism.

Back in October, an Atlanta Journal-Constitution story talked of the wonders of virtual colonoscopy, saying it replaced the dreaded colonoscope and lessened patient risk. It used these words to refer to the technology: "science fiction, Star Wars, video game, Disney World."

Also in October, the Wall Street Journal promoted the growing popularity of virtual colonoscopies.

Neither story mentioned the fact that the U.S. Preventive Services Task Force had stated that same month that "The evidence is insufficient to assess the benefits and harms of computed tomographic colonography as a screening modality for colorectal cancer."

Last week's announcement that Medicare may stop paying for virtual colonoscopies also got little news attention. At least the New York Times reported it. Excerpts:

The Centers for Medicare and Medicaid Services said in a decision posted on its Web site that there was "insufficient evidence" to conclude that virtual colonoscopy "improves outcomes in Medicare beneficiaries."

...the United States Preventive Services Task Force, which advises the government on prevention, said last year that there was insufficient evidence to assess the benefits and harms of the CT technique. Some private insurers pay for the tests; others do not.
...
In its analysis, Medicare said many studies supporting virtual colonoscopy were done in people with a mean age around 58, so results might not fully apply to Medicare's older population.

For instance, older people are more likely to have polyps. So the proportion of people who would have to have a conventional colonoscopy after a virtual one would be greater. That would make the CT scan less cost-effective.

Wish I had a nickel for every story about vagus nerve stimulation that trumpeted it as a treatment for depression.

This week, Medicare rejected Cyberonics’ implantable nerve stimulator, saying the device, the VNS Therapy System, hasn't been shown to be necessary. The $25,000 device is already approved for epilepsy. Cyberonics wanted to expand its use.

Bloomberg News reports “The Food and Drug Administration approved the device in 2005 to treat depression, overruling 20 agency advisers who urged rejection.��?

On the Cyberonics website the company boasted of dozens of news stories from across the country over the past two years, with headlines such as:

"Implant can relieve depression: VNS Therapy is proving beneficial."

"Omahan says she's proof device zaps depression."

"Emerging from the depths of depression."

"The Pacemaker for the Brain" is Saving Lives."

"Up from hopelessness."

"Implanted device helps fight drug-resistant depression - Giving new hope"

Among the media reporting the potential for the device:

U.S. News & World Report
Saturday Evening Post
Redbook
Reuters Health
Arizona Daily Star
San Antonio Express News
El Paso Times
Corpus Christi Caller Times
Toledo Blade
Omaha World Herald
Chicago Tribune
KSAT, San Antonio
WMUR Manchester, NH
WCCO, Minneapolis
KETV, Omaha
KUTV, Salt Lake City
KSL, Salt Lake City,
WBZ, Boston
WCBV Boston
WISN, Milwaukee
WKYC, Cleveland
KTBS, Shreveport
KOMO, Seattle

Each one of those news organizations owes it to their audience to play up the Medicare rejection of the device as prominently as they promoted the potential in the giddy glory days.

If you didn’t see 60 Minutes last Sunday (April 1), go to their website and read the story and watch the video link for the segment called “Under the Influence.� It’s the story of the incredible manipulation of Congress by the drug industry that took place to get the Medicare Part D legislation passed.

Excerpt:

The unorthodox roll call on one of the most expensive bills ever placed before the House of Representatives began in the middle of the night, long after most people in Washington had switched off C-SPAN and gone to sleep.

The only witnesses were congressional staffers, hundreds of lobbyists, and U.S. Representatives like Dan Burton, R-Ind., and Walter Jones, R-N.C.

"The pharmaceutical lobbyists wrote the bill," says Jones. "The bill was over 1,000 pages. And it got to the members of the House that morning, and we voted for it at about 3 a.m. in the morning."

Why did the vote finally take place at 3 a.m.?

"Well, I think a lot of the shenanigans that were going on that night, they didn't want on national television in primetime," according to Burton.

"I've been in politics for 22 years," says Jones, "and it was the ugliest night I have ever seen in 22 years."

Despite what a terrific piece this was, one wonders why it took 60 Minutes several years to catch up to this story. Some viewers wrote to CBS about how late this report came. Examples:

“Great story, AWESOME Story!!! Too bad CBS & 60 minutes waited over 3 YEARS after President Bush Jr. signed the bill into law to report on this. Perhaps if we the American people had heard this story back in early 2004, we would have made different choices when the 2004 presidential election came around.�

“CBS, where the hell were you in reporting this when it happened. Everyone else who was paying attention knew we were being screwed by this legislation, that it was just a give away to the drug companies. but like all (mainstream media), you were totally going to let it pass. Shame on you for taking so long wake up.�

On the listserv of the Association of Health Care Journalists, a journalist raises an important issue that we don't hear enough about. That journalist wrote:

"May I suggest that while Washington is obsessing about Walter Reed, the rest of us should be paying attention to what’s happening in our back yards in the run-up to the deadline for switching Medicare Advantage plans? In many areas, plans have contracted with independent brokers/agents to make a last push to persuade beneficiaries to switch plans. Many broker/agents who signed beneficiaries up for one plan in the fall (to begin Jan. 1) are now urging them to switch before the deadline; that way, they collect commissions twice. There’s a lot of misinformation being spread, a lot of dirty tricks. By the time we get around to reporting on it, the March 31 deadline will have passed and the misinformation campaigns will have been successful."

Have you heard anything about this from your news organizations in your market?