Since 2006, Washington State has had its own sort of Independent Payment Advisory Board for public health payers: the Health Technology Assessment Program.
Tasked with determining if medical services paid for by the public employee health plan, workers compensation and Medicaid are "safe and effective," as the Washington Health Authority describes it, the 11-member Health Technology Assessment committee is comprised of six practicing physicians and five practicing and licensed health professionals -- with binding authority to their votes on what procedures and conditions the public insurance programs should cover.
So far, the committee (all appointed by the Washington Health Authority Administrator) has voted to end coverage for 21 medical procedures, including arthroscopic knee surgery, back pain injections, CT heart scans, lumbar fusion and CT colonoscopies, while establishing conditions on coverage for robotic-assisted surgery, breast MRIs and upper GI endoscopy.
In May, the Health Technology Assessment (HTA) committee finished reviews of catheter ablation treatment for some types of heart arrhythmias and bilateral cochlear implants -- approving both with some conditions -- and it currently has four open reviews. Here's a look at the procedures under consideration:
1. Carotid artery stenting (decision due 9/20/13)
Narrowing of the insides of carotid arteries around the neck and brain, or carotid artery stenois, can lead to mini- and full-strokes; they're thought to cause about 20 percent of all strokes in the country. Although the U.S. Preventive Services Task Force does not recommend screening for the condition, the HTA is considering the comparative effectiveness of several treatments, expecting a rising burden of potential strokes to come with the rise of cardiovascular disease.
Like other clogged arteries, treatment options for carotid stenosis includes several varieties of medical therapies, surgery to remove plaques and the placement of stents. The HTA committee (with members of the public or industry stakeholders invited to comment) are considering several main questions in deciding whether or how to cover those treatment options:
In symptomatic or asymptomatic patients, what is the evidence of short- and long-term effectiveness of carotid artery stenting and medical therapy, compared to medical therapy alone? And what's the comparative effectiveness of stenting, compared with plaque removal and medical therapy?
In symptomatic patients with clogged intracranial arteries, what's the evidence of short- and long-term comparative effectiveness of stenting and medical therapy compared with medical therapy alone?
What is the evidence on adverse events and complications for stenting compared with alternative treatments? Are rates of death or stroke before, during or after the procedure less than 3 percent for asymptomatic patients and less than 6 percent for symptomatic patients?
Is there evidence of differential efficacy or safety for special populations varying by age, gender, race, diabetes, atrial fibrillation or other comorbidities, ethnicity, or disability?
2. Cardiac nuclear imaging (decision due 9/20/13)
"Due to its prevalence," the HTA writes, "accurate diagnosis of (coronary artery disease) is critical."
While nuclear stress tests to diagnose coronary artery disease have helped avoid invasive angiographies and can offer heavier patients more specificity than EKGs, those tests "differ in terms of their diagnostic accuracy, cost, availability, and impact on downstream testing, potential to harm, and other relative advantages and disadvantages," the HTA writes.
For nuclear myocardial perfusion tests, the questions HTA is considering:
How do SPECT (single photon emission computed tomography), PET, and other hybrid imaging modalities compare to other non-invasive functional tests, like stress-ECHO and stress-EKG tests, in improving the outcomes across the patient risk spectrum?
What are the risks associated with these tests, including "contrast and radiotracer reactions, patient anxiety, and radiation exposure"?
What if any benefits and risks are different for patients based on age, sex, race or ethnicity, and comorbidities -- like for obese and diabetic patients? And do the procedure's cost and benefits vary by their clinical settings?
3. Viscosupplementation (decision due 11/15/13)
The HTA is actually re-reviewing viscosupplementation treatment for knee osteoarthritis, after approving it in 2010 for patients who haven't met nonpharmacological conservative treatment and simple analgesics, and only for two courses per year if the first course works.
In the viscosupplementation procedure, a thick fluid called hyaluronic acid (which naturally-occurs in synovial joint fluid) is injected into the knee joint, acting as a lubricant and a shock absorber.
Although viscosupplementation has provided an alternative to nonsteroidal anti-inflammatory corticosteroid injection, there's currently no consensus on its long-term effectiveness. A 2012 research review concluded that viscosupplementation is associated with only a "small and clinically irrelevant benefit" -- but also with "an increased risk for serious adverse events," including including flare-ups and effusions.
The HTA now is asking: What is the clinical effectiveness of viscosupplementation for treatment of osteoarthritis of the knee? And do different viscosupplementation products vary in effectiveness?
4. Hip resurfacing (decision due 11/15/13)
In 2009, the HTA approved hip resurfacing as an alternative to total hip replace for patients diagnosed with osteoarthritis or inflammatory arthritis, and for patients who failed nonsurgical management and are
candidates for total hip replacement. Now, with new evidence from published studies and hip resurfacing registries, the HTA is re-reviewing the decision.
Unlike total hip replacement, hip resurfacing does not involve removing the femoral head and neck or femur bone -- instead preserving those to support future surgery or treatment.
Hip resurfacing does bring some of the same metal-on-metal safety concerns as hip replacement, though. Recent data on metal-on-metal hip systems, the HTA noted, suggest there can be problems with localized-complications (such as "aseptic lymphocytic vasculitis-associated lesions" from vein and artery inflammation), early device failure and metal ion exposure.
In its re-review, the HTA is comparing the effectiveness of hip resurfacing to total hip replacement, and examining the safety outcomes and the costs for both procedures.