Rationing — how will it be spun?

The House of Representatives’ $825-billion stimulus package proposed last week included $1.1 billion to fund comparative effectiveness research — research that evaluates two or more medical technologies or treatments to see which is most effective.

This is welcome news to those who say the need for such efforts to ensure the U.S. gets more value from its abundant health care spending is long overdue.

But not everyone thinks comparative effectiveness research is a good idea. Some say it is a front for rationing health services — for allowing the government to make health care decisions instead of doctors.

Inciting fears of rationing will be an easy card to play in the forthcoming health reform debate. If the national goals are to provide universal coverage and control costs, it seems setting some limits on health care would be necessary.

The use of comparative-effectiveness analysis and separately cost-effectiveness analysis fall squarely within this anticipated debate.

Fans of comparative effectiveness research include key players in the Obama Administration: Tom Daschle, Secretary of Health and Human Services;  Peter Orszag, Office of Management and Budget director; and Carolyn Clancy, acting director of the Agency for Healthcare Research and Quality (AHRQ).

Many developed countries, including Germany, England, Canada and Australia, already invest in this research and use it to decide what health services to pay for. Many health policy experts, health economists and health plan leaders — both public and private — say the U.S. is behind the times.

Nearly everyone agrees that having more evidence to support clinical decisions is a good thing, but there’s strong disagreement on whether it should be mandatory to guide coverage decisions and whether the analysis should factor in the relative costs of treatments.

Scott Gottlieb, a fellow at the conservative American Enterprise Institute and former FDA official, warned Americans this week in the Wall Street Journal about this “mirage” Democrats are calling comparative effectiveness.

“In Britain, a government agency evaluates new medical products for their “cost effectiveness” before citizens can get access to them. The agency has concluded that $45,000 is the most worth paying for products that extend a person’s life by one “quality-adjusted” year. … Here in the U.S., President-elect Barack Obama and House Democrats embrace the creation of a similar ‘comparative effectiveness’ entity … They claim that they don’t want this to morph into a British-style agency that restricts access to medical products based on narrow cost criteria, but provisions tucked into the fiscal stimulus bill betray their real intentions.”

Gottlieb makes comparative clinical effectiveness analysis and cost-effectiveness analysis seem as though they are the same. They aren’t. It’s true that England uses both in its determination, but supporters of the creating a centralized center to do comparative effectiveness research in the U.S. split on whether or not costs should be included.

Comparative effectiveness research and how it could be used to shape health policy is complex with no singular definition, method or form. Proponents may overstate its ability to save money (it actually doesn’t in most countries where it’s used). Opponents may write it off as an underhanded attempt at rationing. THCB will tease apart those arguments over the coming months. Stay tuned.