Coronary CTA and the Frisbee

The death last month of Wham-O cofounder Richard Knerr would have escaped me had I not by chance picked up the Jan. 23 issue of Time. Knerr's death seemed an odd juxtaposition to the cover story trumpeting John McCain's rise to glory. The life experiences of these men couldn't be more different, yet the two struck me as oddly relevant.

The story of McCain, a war hero and current front-runner for the Republican presidential nomination, and his recent rise from the political ashes is well known. Knerr's story is far less so. But many who do not recognize his name probably have played with a toy he figured prominently in popularizing, the Frisbee.

Although Knerr is credited with inventing the toy, he actually took a good idea and made it better. It is said he first encountered flying discs while touring Ivy League campuses in the 1950s. Students were playing catch with the pie tins left over after eating Frisbie pies. But the experience took root only after Knerr's company Wham-O bought the rights to a 1958 patent from Fred Morrison, who had refined the idea into a molded plastic disc.

From pie tin to plastic disc to an "e" in place of an "i," each step was essential to the final result - the sale of more than 100 million Frisbees. Anywhere along the way this progression could have been stopped - just as McCain's current rise could have been capped and still might be.

It is in the development of medical technology that the lessons of innovation and politics merge. And it is specifically the contest over cardiac CT angiography where these lessons can be applied. The last several decades have made it clear that the bureaucracy charged with administering Medicare determines which, when, and possibly even whether, medical technologies are adopted.

In their fight to hem in healthcare costs, Medicare administrators apparently have seen the immediate financial effect of coronary CTA as a threat - a sudden growth in charges associated with the use of this technology. But they have misunderstood its long-term effect, one that has the potential to reduce overall costs while improving healthcare.

These administrators could allow this process to unfold within constraints they themselves put in place for Medicare coverage. They could use the clinical data about coronary CTA soon to be published in peer-reviewed journals to develop a national coverage decision. Instead, they have proposed to stop the process and replace it with publicly contracted research aimed at answering bureaucratic questions. This approach is steeped in the kind of bungling typical of government agencies accustomed to contracting work that would be best handled by an unfettered private sector.

Comments submitted to the Centers for Medicare and Medicaid Services in response to its proposal underscore the support this technology has garnered among professional medical societies, individual providers, and its developers. The final decision whether to implement its proposal is due in March. But the fight by the medical community cannot end there.

This effort by CMS should serve as a warning. Medicare expenditures will grow in prominence as a political issue, especially if the nation slips into a recession and deficits bloom. Administrators charged with rising costs will look for quick fixes, and imaging is a sitting duck.

It is a mistake to believe that clinical evidence and medical logic alone will carry the day. In the fight ahead, we have to realize that CMS is a creation of federal legislators, staffed by bureaucrats, and led by political appointees who are swayed by what happens on Capitol Hill.

Although the companies who make CT scanners may follow a path similar to the one that launched the Frisbee, building upon good ideas and winning sales through marketing, the kind of political savvy and perseverance seen in survivors like John McCain will be needed to see this technology and other clinically valuable ones through. At stake is more than just coronary CTA. It is every promising technology that seeks a foothold to prove its clinical value. It is the health of patients and the fiscal well-being of the nation, as medical imaging provides the tools to manage both.