Physicians

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.

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PissedOffDoc
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PissedOffDoc

Which rich consulting firm gets to administer the CE surveys? Can I have some free money too??
SHOW ME THE MONAAAAAAYY…..

Michael
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Michael

I would love to ask Secretary Daschle or Dr. Clancy to give the top 5 comparative effectivness studies they’d sponsor if the institute is indeed funded. And how does CE sync with Personalized Medicine? I think CE may be important (and easy) if you’re looking at generic vs. brand pharmaceuticals, but for (often pricey) interventions, you need clinical trials, which the CE institute probably wont be funded to undertake. Additionally, how do you enforce the conclusions of CE studies?

Nate
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Nate

I don’t think 3 months is worth 100,000. I’m not in that sittion so it is obviously easier said. I also know myself well enough that I rather give my heirs 100K or absent that have one hell of going out party, 100K is a lot of H&B.

Nate
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Nate

Peter,
There is no such thing as a non political group in the sense you raise. Beyond that I rather have a choice of 100 insurance companies and 100,000 employer plans one of which might cover it then a government dictated single payor plan where I am insured of no opportunity to find it.
Under our current system I also have the option to pay for it myself, something that is not always available in the British system and some other single payor nations.

tcoyote
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tcoyote

Rationing is one of those bloody shirt words, like amnesty in the immigration debate, which raises adrenaline levels and rallies the troops without advancing the public interest. Can we continue with a straight face, given what is going on all around us, to claim that we can easily afford everything our technology sector serves up for us. We already ration care, by income class, to our society’s great shame. Is it somehow shameful to ask if the society is getting value for money when we create new technologies, if the price we pay for seeking the truth here is to… Read more »

Peter
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Peter

“Over utilization is the main driver of inflation now, our present system, UH, or any other system to be effective must drastically reduce it.” “We are going to need a whole lot of tort reform so health plans stop getting sued for dening experiemntal treatments and those with minimial chance of success.” “This is my biggest fear of UH, some politician deciding what my benefits will be and what treatments I’ll be allowed to have based on his campaign contributions.” Nate, do you feel better having an insurance company denying benefits and treatments and would you accept the same denial… Read more »

Steve
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Steve

I for one believe there is a role that can be played by a group of independent professionals scientist and Medical specialist that can look past the cozy relationships of the stake holders. For too long, financial enrichment has ruled the day in our healthcare system. A perfect example is the useless, unnecessary implatation of too many ICDs.
There exist a NON-INVASIVE test that could pre-qualify most ICD reciepients that would eliminate 1/3 of them from this unnecessary implantation.
Microvolt T-wave alternans.

Kathleen
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Kathleen

Some people buy expensive goods or services on a whim, but most of us want to know what we’re getting for our money. I use Consumer Reports to compare value. When it comes to health care services, objective, comparative information should be easily available. So count me in as another fan of comparative effectiveness research. How else will I know that one treatment is twice as effective as another, and costs less to boot!

bruce
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bruce

Partly, tempest in a teacup. If you say show that two treatments are simply equivalent, and it is known that one costs three times as much, people figure that out for themselves pretty quickly. A key issue is that almost none of these decisions are linear. The alternatives usually represent “complex decisions” like, say, deciding to live in a city or a small town, where many factors are involved. Do you want higher risk of dying during surgery, or better 10 year survival if you make it through? Do you want higher chance of success, but more side effects, etc.… Read more »

Nate
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Nate

“If the national goals are to provide universal coverage” This issue should not be tied to universal coverage. No matter what sort of system we have we must control cost. Over utilization is the main driver of inflation now, our present system, UH, or any other system to be effective must drastically reduce it. We need a healthcare Kyoto, well in theory, actually meeting the targets would be nice. We are going to need a whole lot of tort reform so health plans stop getting sued for dening experiemntal treatments and those with minimial chance of success. “I also don’t… Read more »

Peter
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Peter

This will be a tough argument to win for the Administration because providers will be able to use one liner fear mongering to voters who have been trained for short attention spans and surface arguments. I guess one way around it would be for the government to pay for the, “$45,000 is the most worth paying for products that extend a person’s life by one “quality-adjusted” year. …” then giving the patient the option of paying for anything above that. Of course wealthier patients will be able to pay the up charge while less wealthy will charge income discrimination, even… Read more »