Comparative Effectiveness

We love robots as much as the next guy, as long the next guy is our colleague Tom Emswiler. No offense to Shia Laboeuf, but Tom knows how to talk about transformative technological change and its place in health reform. His post on minimally invasive, or laparoscopic, surgery perfectly explained the link between innovation and value in medicine--a complex relation on full display in Wednesday's USA Today article on the da Vinci robot—a four-armed surgical system that is the $1.5 million Bentley of laparoscopic surgery.

As Tom writes: "Technology is valuable, even if it costs more, if it improves outcomes." But, "If a hospital spends a million dollars on a new piece of equipment that doesn't do a better job, there is no value added." This dynamic is essential to understanding that: "Comparative effectiveness is not a way to keep new innovations from patients; rather, it is a way to determine what works best, for whom, when. In this case, new technology results in better outcomes."

For the da Vinci robot, Tom's insights made us think about the good, the bad, and the crucial questions of value and cost for patient and provider. Starting with:

You know you're a health wonk when you get excited at the sight of the word "laparoscopic" in your inbox on a Friday evening. But after four years of thinking about health policy all the time, here I am.

Researchers at Emory have found that "laparoscopic surgery to remove pancreatic tumors or cysts leads to fewer complications and shorter hospital stays."

More:

Compared to standard surgery, laparoscopy resulted in fewer complications (57 percent vs. 40 percent). Patients who had the laparoscopic procedure also had less blood loss and spent three fewer days in hospital (six vs. nine).

Last year I published a column that discussed laparoscopic (minimally invasive) prostate surgery. Blogger/hospital CEO Paul Levy had written about having to buy a new, million-dollar robot that was surrounded by questions of whether it improved quality over "regular" open prostate surgery. Results were mixed.

You may have seen this story in The New York Times today: even people with health insurance end up paying hundreds or thousands of dollars each month for life-saving medicines if they have the misfortune to need a really expensive drug.

Many health plans already "tier" their drugs, making patients pay more if they opt for brand names instead of generics, or if they use a drug that's not on a "formulary" or list of preferred drugs. Now they are asked to pay up to a third of the cost of these new, very expensive drugs for diseases like multiple sclerosis, hepatitis C, hemophilia, rheumatoid arthritis, and some cancers. New treatments can cost $100,000 or more a year. "The system means that the burden of expensive health care can now affect insured people, too," Times reporter Gina Kolata writes, adding that the patient's share of these drug bills can be more than they pay for housing in a month, or even more than their entire monthly income. And for chronic diseases, the drug bill isn't a one-time occurrence. Patients have to take them month after month, year after year.

"It is very unfortunate social policy," Dr. James Robinson, a health economist at the University of California, Berkeley told the Times. "The more the sick person pays, the less the healthy person pays."

Earlier today we put up a guest post by Robert Berenson of the Urban Institute on the troubles with a Medicare pilot program on disease management. Here's another interesting take by Gooznews' Merrill Goozner. Merrill doesn't rule out the value of (good) chronic disease management, perhaps through medical homes, but he also shares our belief that we need a lot more comparative effectiveness research so we know how to spend our health care dollars more wisely:

To squeeze out short-run savings to cover the uninsured, government programs need to develop a strategy to eliminate some of the wasteful use of drugs, procedures and tests that now permeate the system. There's a growing consensus to set up a comparative effectiveness agency in the U.S. to combat that waste. But even this long overdue reform can run off the tracks if it isn't done the right way, an issue I'll address later this week.

Our colleague Tom Emswiler has also posted on the emerging consensus around comparative effectiveness, and he'll address it again too.

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).

Dr. John Kitzhaber, physician, former Oregon governor, health researcher and prophet of comparative effectiveness, ended a provocative speech about health care not with graphs and charts and reams of numbers but with a photograph of flowers and the words of a poet, tending his garden for the last time. He wanted the flowers to bloom, he said, for the next generation.

The flowers represent the health care system in America, and Kitzhaber, now the president of the Estes Park Institute and director of Center for Evidence-Based Policy at the Oregon Health and Sciences University in Portland, has been a prominent voice in reminding us that the problem in health care isn't just about how we pay for it. It's about how we deliver that care, how good that care is, and how we make sure people get what they need when they need it. Ordinary people don't care about "health care" per se, he reminded his listeners. They care about health.

Medical imaging, such as CT scans and MRIs, has become synonymous with medical cost growth, and both private insurance and Medicare looking for ways to rein in costs, according to a recent AP article by Linda Johnson.

Citing work done by the Center for Studying Health System Change, the article noted that from 2000 to 2005 the use CT scans in the U.S. rose from 12 scans per 100 people to 22-with each test generating between $500-$1000 in revenue. During that same period, Medicare's spending on imaging services nearly doubled from $6.4 billion to $12.0 billion, accounting for 23 percent of total outpatient hospital payments in 2005, according to MedPAC-Congress's advisory committee on Medicare.

Today in Washington, the House and Senate consider their respective versions of the budget before they close up shop for two weeks of spring recess. By reading the budget you can usually get a sense of the big-ticket items, but smaller-ticket items are usually left out of the text in the House, and only added in the Senate by floor amendment.

That's why I'm so surprised that the budgets of both Rep. Spratt and Sen. Conrad included specific text to create a reserve fund for a public-private entity for comparative effectiveness research -- i.e a way to find out what really works for patients and at what cost.

As the Senate Budget Committee's supplementary materials state:

"The purpose of such research would be to evaluate and compare the clinical effectiveness of two or more health care interventions, treatment protocols, procedures, medical devices, diagnostic tools, pharmaceuticals, and other processes or items used in the treatment or diagnosis of patients. This information could lead to savings over the long-term by allowing providers to avoid treatments that may be clinically ineffective, while at the same time improving health care outcomes."