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QUALITY: Comparative Effectiveness Is About Caring Effectiveness

February 12, 2009 - 10:19am

Imagine plunking down more than $2 trillion a year and not knowing what you are getting for it. Imagine that what you are purchasing gets more complicated and convoluted every year. Imagine that lives, literally, hang in the balance.

Then imagine that someone comes up with a sensible approach to solving or at least shrinking the problem. And they get hit on the head for their efforts.

Welcome to the world of comparative effectiveness.

The partisan warfare over the stimulus bill (which frankly has surprised some of us with its intensity—Judd Gregg where are you?) gives us glimpses of some ugly battles ahead in health care. Comparative effectiveness research is an early battleground. Advocates range from the Institute of Medicine to the AARP; both Sen. John McCain (R-AZ) and President Barack Obama advocated some form of the research during the presidential campaign. The Medicare prescription drug law, which was largely written and backed by the Republicans, explicitly authorized comparative effectiveness research. But critics, who as the Wall Street Journal reported this week include powerful drug companies and medical device makers, say it is a first step toward government rationing or penny-pinching-driven medicine. Conservative commentators have launched a full-scale assault on the concept using some pretty shrill and scary imagery.

But comparative effectiveness is just what it says. Comparing two or more treatments, therapies, drugs and devices, and figuring out which one works better for patients. There is room for legitimate debate—indeed, the debate has already begun and has been part of the stimulus fight—about whether costs should be an intrinsic part of that equation, or whether cost-benefit analysis should be a separate, second step. But the primary goal of comparative effectiveness is just what it sounds like. Compare two or more drugs, devices, or other interventions, and figure out which works best in which circumstances. If a really cheap old medication works way better than a really expensive new one, it should be pretty darn clear which should be the first line of treatment for most individuals. If a really expensive new drug prolongs lives or controls symptoms or eases pain, then we'll have reason to spend the money (why some of these drugs cost so much is a whole different issue, as Gooznews often reminds us). In many many cases, the answers won't be so clear-cut, or they will change over time as we learn more. But we'll have data and science—not well intentioned guesswork or pervasive marketing—on which to base clinical decisions. Yes, the goal is to spend smarter. But it's also to make people healthier. Health is, after all, the point of health care.

The AARP's CEO Bill Novelli put it aptly:

They're at it again. Opponents of health reform are now using scare tactics in a misguided attempt to stop progress in its tracks, blocking attempts to fix the broken health care system that is hurting American families and our economy.

The latest attacks revolve around a smart policy in the economic recovery package that would fund ‘comparative effectiveness research'—a wonky term that just means giving doctors and patients the ability to compare different kinds of treatments to find out which one works best for which patient.

Opponents—like some drug companies and medical device makers—don't want this research. They fear it will cut the profits they make on ineffective drugs and equipment.

But they won't tell you that this research could save your life by giving your doctors better information so they can prescribe the best treatments available to you.

Really, it's not like the AARP is going to be out there agitating for something that will prevent older Americans from getting good health care!

But if you don't like what the AARP and Consumers Union discovered in their recent research and forum on the subject, see what the Institute of Medicine has to say. IoM had a conference with top policy experts on evidence-based medicine in 2007 and outlined the main issues in comparative effectiveness in a 32-page report last summer. The IoM wrote:

Medical care decision-making is now strained, at both the level of the individual patient and the level of the population as a whole, by the growing number of diagnostic and therapeutic options for which evidence is insufficient to make a clear choice. Biomedical insights and medical innovation continue to advance opportunities to increase the health and life-span of the American public, yet to capitalize fully on this potential requires enhanced capacity to ensure that decisions, in the face of increasing complexity, can be supported and guided by the best available scientific information.

The information gap is growing daily:

As the boom in pharmaceuticals, devices and biologics has left us with a need for information on clinical utility and as innovations in the pipeline come to fruition, the information gap will widen. The rate with which new interventions are introduced into the medical marketplace is currently outpacing the rate at which information is generated on their effectiveness and the circumstances of best use. If trends continue, the ability to deliver appropriate care will be strained and may be overwhelmed.

So when a doctor prescribes something for us or our families, we want to know that the doctor has a scientific reason for doing so. When an insurer says we can or cannot have something, we want to know the insurer has a scientific, not monetary, reason for doing so. When a drug or device comes on the market, we want to know it has a scientific reason for being there. As the Institute of Medicine and others have pointed out, there are lots of unresolved questions about who should do the research, how it should be funded, and precisely how to use the data in our payment policies. But there are answers to those questions about the framework. And once we answer them, we can get on to the questions that really matter: What works?