QUALITY: Consensus Developing Around Comparative Effectiveness

I was expecting a battle royale at last Friday's Alliance for Health Reform event on comparative effectiveness. After all, two of the guests of honor, David Nexon from AdvaMed and Karen Ignagni from America's Health Insurance Plans (AHIP), were from opposing sides of the debate. I was struck though by the amount of agreement among the panelists at Comparative Effectiveness: Can We Get Better Health Value for the Dollars We Spend?

A point of contention in the ongoing debate about comparative effectiveness -- how we figure out how well and at what cost drugs or devices or treatments or procedures work vis-a-vis alternative options -- has been what kind of agency or entity should oversee the research. The device industry has been portrayed as being quite skeptical; I saw that for myself last year when I attended InHealth's 2007 Symposium. But I was pleased at how supportive Nexon sounded, and it makes me think the medical device industry's opposition is overstated. This shouldn't have been too surprising, as Ann-Marie Lynch, commenting for AdvaMed at MedPAC's April 2007 meeting, sounded cautiously supportive as well (p. 101).

Nexon addresssed what the shape and scope of the agency should be. His chief concern was about using cost to determine medical decisions. Ignagni took the other view, saying that ignoring cost in the face of high projected medical inflation would be "putting our heads in the sand." She also made a very reasonable point when she said most of health plans in her organization will not look at this as a stark coverage/no coverage decision. More likely, they would give patients some options, but if they went for the ones that scored lower on the comparative effectiveness ladder, they might have to pay a bigger share of the cost. (Hat-tip to Alan Garber of Stanford and reference pricing).

The important thing is to get the long-overdue research started; as we find out what works, we will inevitably learn about what various treatments cost. If two procedures/devices/drugs have exactly the same effectiveness for a certain population (me-too drugs are a great example; hat-tip GoozNews), then the more expensive drug should be reference-priced higher by insurers. That way other people in the insurance pool don't have to bear the cost of one person's champagne taste for what could be achieved with a cheaper drug. But if a slightly more expensive procedure/device/drug is more effective for certain populations, then it should be only marginally higher in price, if at all. Insurers already make these decisions; in the future these decisions will simply be better informed.

Occasionally, comparative effectiveness research will uncover procedures/devices/drugs that are harmful to large populations; Vioxx and Lung Volume Reduction Surgery come to mind.

With such consensus, we think it's highly likely that Congress will pass legislation this year establishing a comparative effectiveness institute (or at least taking a big step toward it). Senators Max Baucus (D-MT) and Kent Conrad (D-ND) are crafting a bill to create a public-private entity and Representatives Tom Allen (D-ME) and Jo Ann Emerson (R-MO) introduced a similar bill last year. Representative Pete Stark (D-CA) also had language in the House-passed version of the children's health insurance bill. Gail Wilensky published an important piece in 2006 about what such a center should look like.