ACP: Putting effectiveness into the health care equation: Rational or rationing?

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

“Effectiveness” has become a buzzword these days in discussions about healthcare reform. It is often accompanied by different preceding modifiers, such as “cost” or “comparative,” each conjuring up different images in the minds of physicians, patients, insurers, and the pharmaceutical industry. Some say that cost effectiveness and comparative effectiveness are just code words for rationing, whereas others say that consideration of these two concepts is a rational approach to patient care and to controlling escalating healthcare costs.

Perhaps these emotionally charged and divergent reactions to the terms “cost effectiveness” and “comparative effectiveness” can be avoided by focusing on the word “effectiveness” and the need to minimize care that is overused or misused.

Cost effectiveness

The term “cost effectiveness” typically implies a consideration of the benefit of a diagnostic or therapeutic intervention relative to its cost. The benefit is often quantified by improved survival, either in absolute terms or after adjustment for quality of life. This type of analysis necessarily raises some sticky questions: How much is a year of life worth? How do we compare a year of “high quality” life with two years of “mediocre quality” life, and whose standards do we use for judging the quality of life?

I think we can bypass the need to address such unanswerable questions by first focusing on low-hanging fruit, namely whether a particular diagnostic or therapeutic intervention is at all worthwhile for patient care. For example, do patients with chronic low back pain need expensive imaging studies of their spine? When are repeated and expensive diagnostic studies needed to follow a patient with a particular chronic illness? Eliminating unnecessary tests that do not directly improve a patient’s care is rational, not rationing, and a critical component of helping us get out of the current healthcare quagmire.

Comparative effectiveness

Comparative effectiveness, on the other hand, compares the relative benefit of two or more forms of evaluation or treatment. Again, some react negatively to this concept, saying either that it limits physicians’ independence in decision-making, or that it is also a form of rationing of care. But doesn’t a consideration of comparative effectiveness go to the heart of how we as physicians should be making decisions?

At present, FDA approval of a drug requires that it be better than placebo, not that it be compared against another drug. However, what physicians and patients need is an understanding of how one treatment fares against another. We are a society that thrives upon ratings and comparing products, whether we’re talking about cars, colleges, or dishwashers. Why shouldn’t we apply the same approach to our health, trying to understand whether treatment A is better than treatment B?

If treatment A is shown to be better than treatment B, favoring the use of treatment A or limiting the use of treatment B is rational use of healthcare, not rationing. Rationing, on the other hand, would be limiting the use of treatment A, the favored treatment.

Of course, things are not so simple. What if treatment A is more effective, but treatment B less expensive and not a bad option? This shifts us from the realm of comparative effectiveness to the realm of cost effectiveness, where value judgments may complicate the interpretation of scientific data. Because of this complexity, I would propose that we at least strive for “effective” care — i.e., care that assures we are making clinical decisions based on effectiveness, and not overstepping the boundary of effectiveness by misusing or overusing the diagnostic and therapeutic options at our disposal.

Even before we tackle the more nuanced decision process that incorporates dollars and value judgments, we can significantly reduce cost and improve our healthcare system by assuring that we provide care that is effective, not overused or misused.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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