I believe there are two distinct reasons why medical innovation is threatened in our health care system in the US.

First, I strongly believe that the misaligned payment systems drive inappropriate treatment choices and delivery. This includes differentials in payment by site of service and separate physician payments for procedures that cause inappropriate utilization.

Second, health care policy makers, out of touch with coverage and payment systems, do not truly understand how medical technology fits and is adopted within the framework of coding and coverage systems. It causes manufacturers to force fit new technology into payment and coding systems that have no reflection on true costs or value… To address either explosive volume or costs of a new procedure or service, technology is subject to a threshold of payment and coverage criteria that ultimately causes a true disruption in innovation and dissemination of medical breakthroughs.

If many of the current commonly accepted medical treatments were subject to the level of irrational evidence hurdles required now, we would see a dramatic, stifling of medical advancements.

Having said this, it is critical that we begin to assess how we can begin to consider new approaches for payment and adoption of innovative technology and treatments that embrace the concept of value based on improved patient outcomes.

The only way to truly drive reasonable, value-driven care, is to reform payment methodologies that embrace the concept of an episode of care specifically incorporating the practitioner within that global episode.

As long as the end-user is paid separately for performing or using a service, utilization and treatment choices will always be suspect of over-utilization (or underutilization if payment is inadequate). Surely any educated health care professional is aware of the credibility of studies conducted within a system such as Kaiser where the end-user has no financial incentive to drive an intervention. Second, coverage thresholds and evidence requirements (comparative effectiveness?) should be based on a rational process based on risk with the reasonable expectation that data will be collected and analyzed over time (a form of conditional coverage).

We are proud of the medical achievements and access to incredible medical choices in the US. If we continue to increase the barriers to entry, all patient care will be compromised. We have to continue to force ourselves to avoid the tendency to err on the side of more regulation—health care is not Wall Street! Health requires experimentation and some element of risk to constantly achieve the medical success.

It is imperative that we begin to realistically approach new ways to encourage innovation and embrace medical experimentation for improved patient care. If we continue to strictly regulate health care choices based on the notion that costs will be controlled by limiting access through coverage conditions, we will only slow medical innovation that we crave.

This entry was posted on Monday, October 6th, 2008 at 9:02 am and is filed under Coverage Policy, Innovation. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.