“Shocking chasm between Medicare coverage and clinical evidence”

That’s a phrase used by Rita F. Redberg, MD, University of California San Francisco cardiologist and the editor of Archives of Internal Medicine, in her New York Times opinion piece, “Squandering Medicare’s Money.”


Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:

• Medicare pays for routine screening colonoscopies in patients over 75 even though the United States Preventive Services Task Force, an independent panel of experts financed by the Department of Health and Human Services, advises against them (and against any colonoscopies for patients over 85), because it takes at least eight years to realize any benefits from the procedure. Moreover, colonoscopies carry risks of serious complications (like perforations) and often lead to further unnecessary procedures (like biopsies). In 2009, Medicare paid doctors more than $100 million for nearly 550,000 screening colonoscopies; around 40 percent were for patients over 75.

• The task force recommends against screening for prostate cancer in men 75 and older, and screening for cervical cancer in women 65 and older who have had a previous normal Pap smear, but Medicare spent more than $50 million in 2008 on such screenings, as well as additional money on unnecessary procedures that often follow.

• Two recent randomized trials found that patients receiving two popular procedures for vertebral fractures, kyphoplasty and vertebroplasty, experienced no more relief than those receiving a sham procedure. Besides being ineffective, these procedures carry considerable risks. Nevertheless, Medicare pays for 100,000 of these procedures a year, at a cost of around $1 billion.

• Multiple clinical trials have shown that cardiac stents are no more effective than drugs or lifestyle changes in preventing heart attacks or death. Although some studies have shown that stents provide short-term relief of chest pain, up to 30 percent of patients receiving stents have no chest pain to begin with, and thus derive no more benefit from this invasive procedure than from equally effective and far less expensive medicines. Risks associated with stent implantation, meanwhile, include exposure to radiation and to dyes that can damage the kidneys, and in rare cases, death from the stent itself. Yet one study estimated that Medicare spends $1.6 billion on drug-coated stents (the most common type of cardiac stents) annually.

• A recent study found that one-fifth of all implantable cardiac defibrillators were placed in patients who, according to clinical guidelines, will not benefit from them. But Medicare pays for them anyway, at a cost of $50,000 to $100,000 per device implantation.

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Kate Murphy

May 31, 2011 at 10:35 am

If Medicare would cover only those tests and procedures for which there is good evidence, we would waste less Medicare money.
Also, having uniform decisions for Medicare coverage, rather than making those rulings regionally would help patients and doctors know what will be covered.
If there are evidence-based exceptions to the rules like annual colonoscopies for patients with inherited colorectal cancer, they also should be clear.
If patients want to choose to step outside the rules, then the cost is theirs.
Unfortunately, howls of unfair and decisions should be made by individual doctors and patients will accompany any such approach to making Medicare viable.
The “doctor does not always know best.”
Both patients and Medicare funding suffer when treatment is not evidence-based.
There is indeed a “shocking chasm.” Filling it with what we know and not what we wish would make a big difference.