Wednesday, February 11, 2009

Will comparative effectiveness research lead to government-run health care?

Out of the more than $800 billion in economic stimulus being considered by Congress, a provision to spend a little over $1 billion on comparative effectiveness research (CER) is drawing outsized attention from conservative critics.

George Will says that "CER, which would dramatically advance government control - and rationing - of health care, should be thoroughly debated, not stealthily created in the name of 'stimulus.'"

Today, The Wall Street Journal opines that "giving government exclusive control over electronic health information and reporting is a step toward 'comparative effectiveness' research. That in turn will be used to impose price controls and deny some types of medical treatment and drugs. And because government is able to skew the whole health system through Medicare and Medicaid, comparative effectiveness could end up micromanaging the practice of medicine."

If this were true, why would the National Business Group on Health urge Congress to support CER? (The Fortune 500 companies that are members of the NBGH aren't types that usually favor government-run health care.)

If this were true, why would ACP, which represents the very same practicing doctors who the WSJ says will be subject to micromanagement, support CER?

The answer is that rather than leading to micromanagement of clinical decision-making, CER has the potential to improve decision-making by patients and their physicians.

CER "will provide critical information to physicians and their patients to allow them to engage in an informed shared clinical decision-making process" concludes ACP in a 2008 position paper. It "has the potential to reduce unwarranted variations in treatment among providers, increase patient accuracy in expected treatment outcomes, and provide patients with greater comfort in the treatment choice made."

It isn't as if physicians and patients aren't already subject to controls and micro-management. Every day, decisions are made by insurers on which services will be covered. Doctors have to produce reams of paperwork to justify deviating one iota from the insurers' guidelines. But the processes used by insurers to decide what will be covered or not are done in widely inconsistent ways, lack transparency, and don't always rely on the best available evidence.

In my mind, CER isn't about giving the government control over health care, but giving physicians and patients transparent and evidence-based information to make their own decisions.

The WSJ usually sings the praises of "consumer-directed" health care. But how can patients direct their own health care if they and their doctors don't have access to the best available research evidence on the relative effectiveness of different treatments?

Today's question: Do you think that funding an independent effort to conduct research on comparative effectiveness will (1) help improve physician and patient decision-making or (2) lead to government micro-management and control over health care decisions?

6 comments :

Jay Larson MD said...

“One of the first duties of the physician is to educate the masses not to take medicine”
Sir William Osler

CER will help improve physician and patient decision-making. In a sense, physicians already do CER by being in practice. Over the years, physicians develop a sense of therapies which work and those which are only a passing phase. With the current state of pharmaceutical advertising, it is challenging to separate good recommendations from advertized recommendations. The main losers with CER will be the pharmaceutical companies and medical device manufactures who produce products that are ultimately shown not to be of benefit.

For those that are paranoid that CER will lead to government micro-management and control over health care decisions, please refer to: Health Provisions In The American Recovery And Reinvestment Act Of 2009: Frequently Asked Questions at http://finance.senate.gov/press/Bpress/2009press/prb021009b.pdf

Steve Lucas said...

Comparative effectiveness should lead to better decision making on the part of physicians and patients. I remember a comment on a different blog a long time ago concerning the UK's NICE. While admitting all of its problems a doctor stated it was "liberating" to have the guidelines since it allowed him to focus on the patient in those end of life situations.

With nobody paying for "treatments" they had to focus on the situation at hand and deal with it in productive manner. With unlimited third party payment important decisions are never made and the end results are often vast sums of money being spent with no improved quality of life.

Steve Lucas

Realistic said...

In thinking about the CER, Why do I think of the quote" The road to hell is paved with good intentions?" (possibly by Samuel Johnson )

I am concerned that CER will have unintended consquences. According to reports "Ruin Your Health With the Obama Stimulus Plan": Betsy McCaughey (bloomberg), the provisions of the stimulus bill have the potential to coerce physicians , under penalty of law, to follow government issued guidelines. If this is true , does the ACP support this?

This CER Board no doubt will be teaming with "experts" or "expert organizations" who may have conflicts of interests. Are we certain that a national expert physician , making millions from research for a drug company, while serving the CER Board, won't be tempted to influence the Board to develop guidelines favoring the company he or she works for? Have we not seen recent problems at the FDA which highlight the dangers of the revovling door of docs working for industry and government? Where will the checks and balances be once this board becomes omnipotent?

In the final analysis, will a physician and patient be able to choose the individualized treatment for the patient without asking the CER Board for permission? Does anyone really think that calling a government agency will be any more pleasant than calling an HMO?

Alan Terlinsky MD
Arlington, VA

PCP said...

Sadly comparative effectiveness research will turn out to be yet another tool which Payers will use to brow beat the medical profession into submission.
If I sound cynical, every experience I have had interacting with them in the last decade indicates this.
From an idealistic perspective, this sounds great, but as our health care system is currently structured, it will be yet another nail driven into the medical profession.

DrWes said...

CER and the results obtained depend, first and foremost, on the objectives one desires to reach. The most "effective" treatment at sustaining life might ultimately result in the highest cost to the health care system in the long run, whereas the most "effective" treatment in terms of cost, might be to let the patient die.

Who will decide which therapy strategy is most "effective" in each of these cases? How can we possibly make such complicated medical issues a boilerplate template?

Keith said...

Comparative effectiveness research is an essential part of making health care decisions more rationale. It gives the primary care physician the basis for making a case for suggesting a more cost-effective strategy might be in the patient's best interest. Many incredibly expensive diagnostic and treatment strategies are being adopted by medicine without such research. How can one temper our enthusiasm for trying the latest and greatest expensive interventions without gathering such research? I hardly call population based information gathering to make informed decisions rationing!