The View From Your Sickbed

by Patrick Appel

A reader writes:

The letter from the reader with acid reflux would be much more helpful if he had named the procedure. Most reflux is treated today with either medication to reduce the acidity of stomach contents or a procedure called fundoplication. There are several alternatives, but none are used much. One, the Enteryx implant, was recalled by the FDA.

Without knowing which one his doctor advocated it is hard to comment, but I wouldn't rely on the opinion of one doctor who favored the procedure as the last word on its safety and effectiveness. The idea that insurance companies can and will suppress a cheap and effective treatment because its very cheapness and effectiveness may generate demand and cost them money is a very serious charge. You don't have to believe that insurers are angels to be skeptical.

First, insurance companies are part of the business of medical care and their profits have grown with the business as a whole. If doctors had nothing to offer but aspirin and bed rest, no one would buy insurance. It may be in an insurer's interest to avoid paying for a particular instance of treatment, but it does not follow that the insurer would be better off if the treatment did not exist at all. By analogy, medical malpractice insurers fight every claim, but their business depends on there being claims. Health insurance premiums are adjusted frequently, so carriers can raise them as new treatments emerge.

Second, the class of reflux medications in use today, the proton pump inhibitors, are a huge cost to insurers. The leading brands, Prevacid and Nexium, are right behind statins like Lipitor as the most prescribed drugs. If insurers did make decisions the way the letter writer imagines, cheap surgery might look good.

Third, there are many active participants in the healthcare system with economic interests in conflict with those of the insurance companies. If doctors, medical device makers, and hospitals stood to benefit by the widespread adoption of a new technology, insurers would be unable to suppress it. They have no control over clinical trials, which are funded by the government, universities, and manufacturers, or over medical journals. Competition between branches of medicine helps as well. A procedure that could be done by a gastroenterologist instead of a surgeon would be of great interest go the gastroenterology community,
who would publicize the failure of insurers to cover it.

The best example of this is the way angioplasty and vascular stenting have replaced much coronary artery bypass grafting. These are less invasive and expensive substitutes that have expanded overall demand. This is a much bigger field with billions of dollars at stake. If the insurance companies exhibited the behavior and had the power that the writer hypothesizes, they would have killed angioplasty.

One more reader:

Likely your reader's doctor did not hear, or did not pass along, the correct history of GERD treatments. GERD is treated non-surgically by partially closing the esophagus where it enters the stomach, thus reducing the amount of stomach acid that splashes up out of the stomach. There were several non-surgical procedures to treat GERD that were approved in the US, and later withdrawn. A few years ago when I was looking to treat my GERD these non-surgical treatments were available:

Enteryx, which injected plastic into the wall of the esophagus. This device was later withdrawn from the market after patients died after the plastic was injected incorrectly.

EndoCinch, which uses sutures to fold up some of the inside of the esophagus. It's use declined after it was shown that the sutures did not last very long.

Stretta, which uses high frequency radio waves to literally burn parts of the esophagus. This created scar tissue which would expand thus partially closing the esophagus. It is still in use.
None of these treatments had then, or have now, good published scientific studies that prove their effectiveness. At that time, my insurance company would have paid for any of these treatments. It is perfectly reasonable and even generous for an insurance company to pay for a new unproven treatment that looks promisingly cheap and effective. And it is also perfectly reasonable for an insurance company to later withdraw approval for a treatment that is discovered to be dangerous or ineffective. This is how innovation works.