Comparative Effectiveness

We came to the National Press Club today ready for a debate on health care and entitlement reform. What we got was a lot of consensus on the serious challenge of health care cost growth and the need to do everything in our power to bend the cost curve. That, and an interesting bowl of gazpacho with chunks of watermelon in it….

Our cold soup confusion aside, we were pleased to participate in the panel of experts put together by our colleague Maya MacGuineas, Director of New America’s Fiscal Policy Program and President, Committee for a Responsible Federal Budget.

Our co-panelists addressed the need to make hard choices in health care and the budget and the potential of Medicare to drive changes in the system. With such a broad range of expertise in fiscal and health policy, there was naturally some disagreement on priorities and political viability of different options. But every panelist shared the goal of getting health care costs under control. The purpose of our presentation was to show that there are real, tangible ways of holding down costs that can provide the basis of meaningful reform.

 You can find the whole discussion webcast here. Below are a few of our key themes:

The New York Times continues its "The Evidence Gap" series, this time examining new vaccines that aim to prevent cervical cancer. It's been a terrific series of articles, underscoring what many in the health policy world have come to accept, but too few in the real world of patients (and often their doctors themselves) understand: more and new medicine isn't always better medicine; and, we often spend money on drugs, tests and procedures without really knowing if they are more helpful than simpler or older and cheaper alternatives.

Senate Finance Committee Chair Max Baucus (D-MT) and Senate Budget Committee Chair Kent Conrad (D-ND) have introduced legislation to establish a public-private comparative effectiveness institute, CQ HealthBeat (subscription) reports. Many health policy experts have called for such an initiative as necessary to control costs and improve quality. The senators envision it as a nonprofit private entity, not a federal agency, governed by a public-private board. Congressional Budget Office Director Peter Orszag has estimated that the U.S. could save up to $700 billion annually in health spending if we could avoid treatments that do not lead to the best medical outcomes.

Earlier this week we gave you an overview of the new Medicare Payment Advisory Commission (MedPAC). Today we want to go into a bit more detail on MedPAC's ideas about a comparative effectiveness research entity—including governance models and funding streams.

MedPAC believes the entity should sponsor and fund studies that compare the clinical effectives of two or more procedures, drugs, or devices to investigate what works well, for whom, when. It would be independent (non-political) and produce objective information in a transparent fashion. Interestingly, it would make no coverage or payment recommendations—although patients, payers, and physicians are free to reach their own conclusions using the data. It would be funded with both public and private money, have an independent board, and contract most research out to outside groups, including academic research centers, the NIH, and the Agency for Healthcare Research and Quality.

If you think we've got problems here in the U.S. developing evidence-based medicine, just think about the challenge in a place like Russia. Health writer and blogger Merrill Goozner just spent two weeks reporting in Russia, and we were fascinated by his piece on the Scientific American website.The problem, he writes, begins in the medical schools, where "young doctors receive almost no instruction on biostatistics, epidemiology and methods of decoding the evidence generated by clinical trials." Russian doctors make about $800 a month, meaning getting access to western medical literature is often out of reach (besides, it's in English). So while neither our health system nor our lawmakers have yet figured out how to stimulate more comparative effectiveness research (and how to get the research acted on), at least we aren't treating pulmonary patients with aerosolized salt dust in "cave-like rooms"—a practice that's been common in Eastern Europe for two centuries, but according to Goozner, never systematically studied.

The Washington Post health section this week ran an essay by Darshak Sanghavi, a pediatric cardiologist and assistant professor of pediatrics at the University of Massachusetts Medical School. Sanghavi wrote about the work of the Dartmouth Atlas researchers who have found significant variations in what kind of care people get across the country, how much it costs, and what the outcomes are. In brief—we'll explain a bit more below—years of research by the Dartmouth team has found that more spending, more technology ,and more specialists doesn't equal better health care. They argue that Medicare could cut its costs by about a third and patients would actually fare better.

A lucky 13 top-notch health policy wonks outlined concrete and achievable stops to improve quality, reduce cost, and repair our health care system in the May/June issue of Health Affairs. For instance, beyond the common refrain for increased use of "evidence-based" medicine, the "Quality Crossroads Group" called on Congress to immediately create a national center to support effectiveness research so we can at least get started on examining what treatments work best and when to administer them.

We also liked the call by the authors, including New America's Len Nichols, to replace the fee-for-service payment model with systems that reward clinically effective and efficient population health management--like bundled chronic care episode payments and paying for population health performance.

As we continually say in this space and elsewhere, successful reform must address coverage, costs and quality at the same time. This Quality Crossroads Group outlines better and more succinctly than most how quality improvement, cost containment, and coverage expansion are inextricably linked. Ultimately, the group offered five ways to achieve a high-performance health system:

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."