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.

Comments are moderated before they are published. Please read the comment policy.

  • Michael Kirsch, M.D.

    Comparative effectiveness research (CER) is an absolutely critical element of health care reform. There are billions of dollars wasted in the system, much of which, I regret to say, is caused by we physicians. I think, however, that it may be politically impossible to get CER off the ground because of the stakes involved. Entire companies will be at risk and won’t stand idly by allowing some outside ‘board’ to dismantle them. The drug companies, device companies, hospitals and medical specialists will do whatever it takes to protect their interests. If CER determines, for example, that cardiac stents or colonoscopies (my own procedure) should be curtailed 30%, can you imagine the reaction? Who would we trust to make these decisions?

  • Doc99

    The problem with “comparative effectiveness” is that it is a lagging indicator. As we all know, medicine swings like a pendulum do. For example, tight control of blood sugars in diabetics was SOP in critical care until two recent studies concluded that the tight control group had inordinately high rates of death.

  • SarahW

    “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?”

    This assessment ulitmately belongs to one person or his legal proxy. It belongs to the individual with skin in the game.

    It’s your job to offer what you can, and their job to assess benefit and cost with your help in understanding the possibilities and limits of any treatment and possible effects on day to day living and long range outcome.

    Physicians should not be dictating the answer to anyone, and certainly not when considering whether a treatment is a financial waste or not. That is the purview of the patient, or anyone he has contracted with to pay his costs.

  • Michael Kirsch, M.D.

    While that may may true, there is obvious medical excess occurring everwhere. The emergency room is one of the best examples of this. When I see pts in my office after an ER visit, I am always astonished at the extent of testing that as been done exposing patient to risk and spending unnecessary dollars. I don’t need comparative effectiveness research to convince me that every pt with a stomach ache needs a CAT scan/labs or that every pt with CP needs CAT angios, EKGs, etc. There is so much ‘low fruit’ hanging already.

  • DrMcGregor

    Interesting poin of vew. I think that this can be usefull too – and this –
    I’m agree with SarahW, but i’m not so categorical.
    Thank you for your blog, best regards.

  • Doc99

    Health care reform: what is costly overuse and what is humane?

    Read the whole thing.

  • TrenchDoc

    One other factor in the equation is the “should have known” factor. This is the test or procedure the doc should have done for the palntif in a malpractice. The “effectiveness” of any test/treatment is the one a doc can do to keep him from being sued. That is why a lot of the CTs and speciality consults are done. Studies have shown that 60 percent of patients already have a diagnosis for their complaints before they ever see the doctor. Also 50 percent of thaose patients also have an idea of what tests and treatments they expect to be done. Now if those issues are not addressed and there is a less than optimal outcome somebody is getting sued. Since we get paid for doing more and since patients expect more and since we have a better defense by doing more guess what happens. EVERYBODY gets MORE. Why can’t we just address these issues up front and get to the real reasons for increased healthcare costs? This is not brain surgery to figure this stuff out.

  • jimeyers

    Establishing the effectiveness of healthcare as a prerequisite to providing such care is perhaps a good idea in the abstract but, in practice, an impossible goal. Medicine historically has been evolutionary though plodding. Standards of practice have in the past and continue to develope over time. The current insistence on evidence based medicine cannot apply to the bulk of medical desicion making which is based upon habit, experience, logic, and science. It is not difficult to establish a statistical advantage to one medicine or treatment rather than another. It is simply a matter of designing the study, recruiting the participating hospitals and practitioners, recruiting the subjects, and then wait long enough for any result to be statisticcally significant. The will, money and time does not presently exist to find such support for even a significant proportion of medical practices. Retrospective studies are always suspect and it is hard to justify even such studies in quantiies large enough to subject to meta analysis. Reliable evidence doesn’t exist as a basis for most therapuetic decisions if reliability is defined as a 5% or less chance that the desired effect will have occurred on the basis of chance alone.

    What is reasonable represents a coompromise between scientific fact and pure speculation. When accumulated experience suggests a different course habit should not stubbornly stand in the way while waiting for a degree of scientific and statistical certainty that we can not afford.

    The large amount of “low hanging fruit” is simply a reflection of the extent to which thoughtful practice has been replaced by meaningless tests.

  • Michael Kirsch, M.D.

    My ‘low hanging fruit’ metaphor meant there is a plethora of wasteful practices that could be eliminated without have to perform comparative effectiveness research. I am not referring to medical gray areas where thoughtful and knowledgable practitioners can disagree. I would target the buckshot style of ordering tests and consultants reflexively. The next time you are on hospital rounds, I am quite confident that the evaluation on every case we see could be curtailed without any clinical loss for the patient. I am sure that my own charts are not immune to this disease of medicomegaly.

  • Pankaj Karan,MD

    I love you article and I understand and agree with what you are saying.Problem is that that kind of braing sucking scientific arguements would fail in face of common ignorant uneducated people and unfortunately we have many of them who just want everyting but do not want to pay.I bet they cannot do the same thing when they are buying car or flatscreens TV etc.
    Medical coommunity need to practice evidence based medicined and comparative strudies is one of the tool which will help us to better understand why we should use one ,not other because that is better for patient. An educated and smart pts with reasonably good IQ would want that but a moron would want whatever they think is right and has nothing to do with data or study: ME,me,meeeeee and some of the comments reflect that.

  • steve H

    Dr Kirsch

    please understand that from an ER point of view, this is the first, last and only time we will be seeing the patient. ALL their complaints must be addressed, no matter how insignificant. In my residency, we were told to treat and test every patient as if we were the only one who would ever see them, because most dont follow up, and most are noncompliant.

    This does lead to a great deal of testing, million dollar workups, etc, and yes it is costly, however, the best piece of advice I ever received while in training is this ‘it is better for you to spend your patients money on testing than for them to spend yours for malpractice, real or imagined’.

    Nobody has said how comparative effectiveness fits into my world, and until I get penalized for testing and ruling out the zebra, or until tort reform comes through, my practice will not change.

  • Michael Kirsch, M.D.

    I completely understand your point of view and the pressures that you face. Nevertheless, the ‘ER approach’ is not good medicine. There should not be a need to address all medical issues in a single visit. We don’t do this in the office. Ideally, ER pt should have a reasonable evaluation and should then follow up with an outside physician to reassess the patient and continue the evaluation, if needed. Many of the pt’s ER complaints will have resolved by then. I suspect that we agree on this philosophically, although real world pressures are interfering with medical judgment.

  • jimeyers

    Dr Kirsch is right on. E.D. Physicians are well trained to know the difference between signs and symptoms requiring urgent evaluation and those better left to the internist or other specialist for workup. Knowing when to be thoughtfully patient and when patience is dangerous is part of the job. Steve a shotgun approach buries you with information you don’t need and haven’t the time to thouoghtfully consider. This approach will reslult in more patient dissatisfaction and lawyer inquiries, not less.

  • Happy Hospitalist

    This is one of the best essays I have read in a long time.

  • Michael Halasy

    And Comparative Effectiveness data CANNOT be simply limited to procedures, interventions, devices, and medications. It also HAS to include providers. Which is why I am about to start a CE study comparing PA’s to Physicians in the ED setting on moderately complex diagnoses. We cannot see everything, as we are NOT physicians, but we can see a lot. The question to me, is, how are we doing? Who knows, the results may not shine favorably upon us.

  • Rezmed09

    What good is comparative effectiveness if it does not protect you from lawsuits. Be honest every study has numerous exclusion criterion. Every patient is different – especially when it is “me”. This is a pipe dream. We can’t even reduce antibiotic use much without patients screaming and threatening.

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