Thursday, August 19, 2010

Test for Alzheimer’s?

An e-mail from Health Care Anew follower Ed Ablard calls attention to the emergence of diagnostic methods (spinal tap and PET scans) that are highly accurate in diagnosing Alzheimers, but less so in predicting dementia.

It raises issues of who should have these tests and what should be done for those who come up with positive results.

In present circumstances it seems likely those decisions will for the most part be made by patients, patients’ families, and doctors and paid for by insurance – mostly Medicare. It may be that there are, or could be, evidence-based conditions in which reasonable people would agree that the benefits of doing the tests are not commensurate with the cost and other consequences. If so, those conditions won’t be known by most of those who make the decisions. The result is that cost will be incurred for tests of questionable value.

As a practical matter, there are two possible sources of guidelines that would address this issue.

One is the insurance company (in this case probably Medicare) which could prescribe the conditions that must be met if the tests are to be paid for.

The other is a local Accountable Care Organization, most likely a hospital, which is financed by means of global payments; i.e., capitation, and therefore has an incentive to avoid costs, particularly those that result in little or no benefit to the patient. That means some limitation on choice of physician.

Despite that limitation I personally would vote for the latter. I would have more confidence in the judgment of a local institution controlled by my friends and neighbors than in that of a national governmental agency subject to political pressures.

Others may disagree, but that is where I come down.

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