Comparative effectiveness research (CER) needs honest discussion

Comparative effectiveness research (CER) is suddenly a hot topic at all the health care conferences.

How come? Everybody agrees that we have to decrease per-capita cost and increase quality. Why? Government programs like Medicare and Medicaid foot more than 50% of our nation’s health bill, and if everything stays the same these programs will go belly up (bankrupt) in 8 years. Big problem.

Health and Human Services (HHS) has defined comparative effectiveness research as conducting and synthesizing research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in “real world” settings. In other words, CER is figuring out what treatments, tests, and drugs work and which ones don’t work.

John E. Wennberg spent a whole career at Dartmouth studying American medicine, and he comes to the startling conclusion that 60% of Medicare is spent on supply sensitive care (physician visits, consultations, imaging exams, and hospital and ICU admissions) and 25% on preference sensitive care (PSA tests, mammography, and elective surgery). Although we assume that this care is based on solid scientific evidence, Wennberg states that “medical science is virtually silent on such matters” as how often to see a patient, what test to order, and whether to admit a patient to the hospital or ICU. Some evidence based medicine experts state that only about 20% of what physicians do is based on sound science.

The American Recovery and Reinvestment Act of 2009 contained $1.1 billion for CER, and the Patient Protection and Affordable Care Act of 2010 put in place a structure including a Patient-Centered Outcomes Research Institute to provide a continuous stream of funding and oversight to CER.

So we just need to do the research, figure out what works, and then have Medicare only pay for treatments and tests that work. That approach will solve the health care budget crisis and pay for care that is evidence-based. Right? Wrong. In the current legislation is language that states that CER findings may not be “construed” as mandates regarding payment or treatment or to deny or ration care.

A quick history of CER in the United States reveals how intense the politics around health care can become. Senator David Durenberger of Minnesota in the 1990s encouraged the government to fund Patient Outcomes Research Teams (PORT) to study the best ways to treat angina, low back pain, cataracts, and benign prostatic hypertrophy. When the 23 member expert PORT panel found little science to support surgery as a first line treatment for low back pain, the back surgeons lobbied Congress. The result was Congress cut CER funding for the PORT; one man’s waste is another man’s revenue.

One way to analyze the intensity of health care in the United States is to take a look at Medicare data for the last two years of life. The Dartmouth Atlas project that Wennberg founded had done just that. In the last two years of life, per-capita Medicare spending at UCLA is $93,842 per patient and $53,432 per patient at the Mayo Clinic. Many have suggested if we could get the entire country to treat such patients like the Mayo Clinic we could save $700 billion a year. Another study looking at the last two years of life found that patients in Newark, New Jersey spend about 35 days in the hospital; patients in Cleveland and San Francisco spend about 20 days in the hospital; and patients in Portland, Oregon, and Salt Lake City, Utah spend only 12 days in the hospital. If the doctors in Portland and Salt Lake City could teach the rest of us how they do it, much of our budget problems would be gone.

If CER is just trying to figure out what is scientifically the best way to diagnose and treat human disease how can anyone be against it?

Princeton health care economist Uwe Reinhardt writing in the New York Times economics blog identifies two groups opposing CER:

“The first group includes individuals or enterprises that book other people’s health care spending as their own health care income.”

“The second group … includes individuals who sincerely believe that health and life are ‘priceless’ – for them cost should never be allowed to enter clinical decisions.”

What seems clear is that American society needs to have a frank and honest discussion about CER, waste, and the American budget deficits. CER itself is not controversial. It is what you do with the results that create political tension and heat. The Kaiser Family Foundation stated the obvious when they wrote recently: “Ultimately, however, conducting research and gaining knowledge about what is clinically effective is only valuable if the findings are used by the health care system.”

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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  • pheski

    Thank you for a nice discussion.

    I would add a third group to the CER opposition: those who believe that care driven by evidence based algorithms is inherently and consistently inferior to care driven by individual practitioners making individual decisions for individual patients. These are the folks who like to say there is no such thing as a smart algorithm.

    Most of us in the active practice of medicine have an instinctive (and, I believe, appropriate) negative reaction to being told what to do. The argument against evidence based algorithms contains its own effective response: for the same good reasons it would be inappropriate to blindly let the algorithm make automatic decisions, it would be inappropriate to blindly reject the algorithm is inherently wrong.

    When talking to patients and clinicians about this, I talk about using the evidence and the evidence driven algorithm to inform my decisions, not to make my decisions.

    Peace.

    P

  • Paul Watson

    ‘When talking to patients and clinicians about this, I talk about using the evidence and the evidence driven algorithm to inform my decisions, not to make my decisions.’

    I don’t think anyone is saying that CER tells physicians what to do. But surely you need to be more accountable for making decisions that go against the evidence, especially if you have a financial incentive in the decisions.

  • pheski

    I agree that CER itself is not an attempt to tell providers what to do. That doesn’t mean it is not used that way by fiscal intermediaries, mid-level bureaucrats trying make their institution more efficient by standardizing processes using an early 20th Century manufacturing model, or by those establishing pay-for-performance incentives. It also doesn’t mean it is not **perceived** by providers as what must be done, rather than as an optimal path for the standardized patient.

    I was speaking to the perception, not the reality, and suggesting that those of us (myself included) who are absolutely convinced that wider application of evidence and evidence based protocols will improve care would get more traction if we were more careful about our language.

    Peace.

    Peter Elias, MD

    • Killroy71

      When insured patients are using OPM (other people’s money) to pay for your judgment and resulting treatment, it’s fair for the entity responsible for dispensing said OPM (insurer) – let alone the patient – to ask you to be accountable for your decisions.

      If there’s a standard of care and your judgment says to deviate from it, you – as a scientist – should be able to explain why this is so. And that should be sufficient, along with tracking your outcomes to see how your judgment is over time.

      Or would you really rather have the cost conversation with every single patient? Because insurance is what allows you the luxury of NOT having that conversation.

  • http://www.preparedpatient.org Goldie Pyka

    In “More Can Also Be Less: We Need a More Complete Public Discussion About Comparative Effectiveness Research” Jessie Gruman gives a patient’s perspective on CER. What helped and what didn’t when she needed to decide about treatment for stomach cancer, her fourth cancer diagnosis: http://tinyurl.com/2a4jymd

  • Killroy71

    This whole discussion of CER cracks me up. When I used to work in alternative medicine, the rap was that such radical concepts as relating nutrition to health/disease was unproven. Hydrotherapy, acupuncture, massage, manipulation, all types of physical medicine waved off as unscientific quackery.

    Now it turns out that much of mainstream medicine isn’t proven either (back surgery, knee surgery, no better results than physical therapy which is – physical medicine!), and that there are factions within it that don’t even want the accountability of CER; standards of care dismissed as “cookbook medicine.”

    Looks to me like doctors of any variety simply want to be left alone to practice their “art” and ignore costs and outcomes, yet get paid by the insurers they gripe about.

  • Tripp Wingate

    NHS is way ahead of us on this journey. Yes Allopathic Medicine can only validate through quality studies about 20% of over 2000 common interventions to be beneficial. http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp

  • Thomas Reid MD PhD FACP

    CER is not the issue….the issue is who manages CER. CER must be left to the medical specialists, not the federal government – otherwise we’ll see more decisions made by non-medical experts and rationing: a la Avastin for metastatic breast cancer.

    Thomas Reid MD
    Hematology-Medical Oncology

  • tripp wingate

    Tomorrow is the birthday of the first of the baby boomer generation.over the next 2 decades there will be a doubling of Medicare beneficiaries from 40 million to 80 million….cost have to be controlled somehow otherwise the Ponzi scheme will collapse…a tragedy of the commons on an epic scale.

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