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Medical treatment under the California workers’ compensation system must be based upon evidence based medicine, that is, treatment that is recommended in published peer reviewed treatment guidelines. But, a new study shows how those guidelines may not consider costs as part of the equation.

According to the article in Reuters Health, researchers found that just over half of the top medical societies with at least 10,000 members considered costs when developing best practices. The other half either implicitly considered costs or didn’t address them at all.

“Even when they said they looked at costs, they didn’t seem to have a clear, consistent or rigorous way to do so,” said Dr. Steven Pearson, the study’s senior author and a visiting scientist in the Department of Bioethics at the National Institutes of Health in Bethesda, Maryland. Pearson and his colleague Dr. Jennifer Schwartz write in JAMA Internal Medicine that while a lot of debate has focused on the cost of healthcare in the U.S., few researchers have looked at whether professional societies develop their treatment recommendations with costs in mind.

Clinical guidelines are often crafted by professional medical societies to help doctors decide which therapies are best for certain conditions. But saying a treatment is not worth the cost may spark fears of care rationing. “It’s obviously very controversial about when costs should be included in the discussion of healthcare,” Pearson said.

But the professional practice recommendations may factor into reimbursement policies among organizations that pay for treatment, like the Centers for Medicare and Medicaid Services.

For the new study, the researchers examined the publicly available clinical guidelines issued by the 30 largest U.S. medical societies between 2008 and 2012 to see which ones discussed costs. More than half – 17 of the 30 societies – explicitly included costs in their discussion of clinical guidelines, four at least implicitly considered costs, three purposely excluded costs and six did not mention prices. The researchers then examined the 279 guidelines published by the 17 societies that included costs in their decisions. Based on that review, they found nine had a formal evaluation system for costs. The other eight societies had several methods to evaluate costs or didn’t mention their process. “I think it’s encouraging the societies are now starting to include costs into their guidelines. And when they decide not to, I think it’s important to be transparent about that,” said Schwartz, a research fellow in the NIH Department of Bioethics.

Dr. Joseph Drozda, from the Center for Innovative Care at Mercy in Chesterfield, Missouri, said he believes more and more societies will be including cost analyses in their guidelines. “(The researchers) caught it on the upslope so I think we’re going to see more attention to cost in guidelines,” said Drozda, the chair of the American College of Cardiology Foundation’s Clinical Quality Committee who wrote a commentary accompanying the new study. “I think clearly there is – over time – more of an interest in incorporating cost issues into guidelines,” said Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians in Philadelphia. “What a lot of organizations are doing – and certainly what we’re doing – is recognizing that there are so many areas of overuse and misuse of care,” said Weinberger, who has written about cost-conscious care but was not involved in the new research. He added that the discussion of costs in healthcare is not about rationing, but finding which treatments offer the best value. “I would really like to see a much more open dialogue between physicians and patients about costs,” Weinberger said.