This is kinda NICE . . .

Kinda. We have monthly faculty presentations here. I always learn something, except when I present, and yesterday I learned a bit about Medicare's National Coverage Determination process. Doctors can't just order up any old licensed procedure or drug and bill for it -- CMS (the wacky abbreviation for the Centers for Medicare and Medicaid Services) decides what Medicare will pay for, and for whom. In other words, patients have to meet certain diagnostic criteria in order for Medicare to reimburse particular services; they won't pay for off-label prescribing.

By an amazing coincidence, in fact, they sent me an e-mail today announcing a new National Coverage Determination, and I think it's a good example. Antiretroviral medications for HIV, and specifically protease inhibitors, can have an unfortunate side effect, called lipodystrophy. They cause abnormal redistribution of subcutaneous fat, which can produce a so-called "buffalo hump" on the back, and leave the face looking gaunt. So, CMS will now pay for dermal injections to improve the facial appearance, but only in people with HIV who have lipodystrophy. You can't get CMS to pay for those Michelle Pfeiffer bee-stung lips. If you back up on the web site you can see all the National Coverage Decisions.

CMS is not allowed to take cost into account, but only medical necessity and "reasonableness." According to the analysis by my colleague, more cost effective interventions are more likely to be approved, presumably because if there's already something just as good or better, and cheaper, the new intervention isn't actually "necessary." So this isn't quite like the UK's NICE -- if there's no better alternative, basically even the most expensive treatments can be approved -- but it does provide a starting point for bringing order and reason to our health care spending. Of course, we don't have a single payer system either, but private insurers keep an eye on these decisions and they do help legitimate their own restrictions.

One consequence that people haven't talked about much of the legislation the president signed yesterday is that when the companies can no longer do medical underwriting, they will have to look for other ways of keeping costs down and competing on price. They won't improve their popularity by screwing people who legitimately need treatments, so they will now have much more incentive to look for reimbursement policies and ways of restructuring delivery that get us more for our money. In other words, even though there isn't much in the way of cost containment in the legislation, maybe we'll get some anyway, as a beneficial side effect.

We already have some basic infrastructure at CMS. Let's build on it.