Comparative effectiveness is a new term that’s been pushed into the health care public square. Get to know it since it’s here to stay. The prestigious New England Journal of Medicine published 3 commentaries on the subject in its May 7th issue. More importantly, this new concept in medical quality measurement has also been reported by the lay press to the public. The debates and discussions that will follow in the coming months will be as calm and civilized as the gladiatorial contests were during ancient Rome.
Comparative effectiveness (CE) aims to determine which medical treatments truly work and which should abandoned. The federal government will be spending over a billion dollars funding studies to try to objectively demonstrate which medical interventions are effective. It is hard to object to this mission. Nevertheless, comparative effectiveness will polarize the medical world. Opposing camps are already preparing for battle because for many interest groups, this may be an existential war. If CE succeeds, then there will be some winners and many casualties whose careers and companies will be ended. Sounds like health care reform will be a fun spectator sport.
Only the most partisan player could deny that billions of dollars are wasted on unnecessary and inefficient medical care in this country. (See related link.)It is a more challenging task, however, to define what wasteful care is. CE research aims to do this. An insurance company or the government, for example, may argue that a stem cell transplant for a relapsing cancer patient is below the efficacy threshold. The cancer patient and his family, however, will have a different view. They, of course, are desperate for any measure that might rescue the patient from death and may cite a few preliminary medical studies that suggest a medical benefit. (While I can’t explain this further in this posting, many medical studies demonstrate a ‘benefit’ that does not really benefit the human patient.) If objective research can demonstrate that a specific test or treatment doesn’t work, or that an alternative is superior, wouldn’t we want to know this?
Comparative effectiveness antagonists say that this is really a stalking horse for socialized medicine, a radioactive political term that was used to help doom the Clintons’ attempt to reform health care in 1993. Others cry that this is really camouflaged medical rationing, as occurs in Great Britain. Let’s not let cries of socialism or doomsday distract us from the need to prove and encourage medical quality. If the government’s current plan is really a poison pill, then opponents need to present their proposal of how to reach the same objective.
CE proponents will vigorously argue their case, but will omit the inflammable terms socialized medicine and rationing from their public briefs. Nevertheless, there will need to be a prioritization of medical tests and treatments if health care reform is to gain any traction. Call it rationing or whatever you want, but the new system will have to accommodate several pesky facts and considerations.
- Billions of dollars are spent on medical care that provides marginal benefit to Americans.
- The current physician and hospital payment system encourages excessive care and treatment.
- Patients are not entitled to unlimited medical care, particularly if they are not paying for it.
- There is no objective agency that evaluates medical effectiveness and appropriateness. At present, medical effectiveness is declared by those who have a financial interest in the device or treatment.
- Money gained by eliminating unnecessary care could be used to fund proven and underutilized treatments, such as immunizations, mammograms and other preventative medical tests.
The reality is that there is no unlimited pool of money to fund every available medical treatment for every patient. Priorities must be assigned. I view comparative effectiveness primarily as a quality initiative, not a cost control effort, but the financial savings would be staggering. Afterwards, we can argue about where to direct these newfound funds. To insure 46 million Americans? To the National Institutes of Health to fund studies on cancer research? To subsidize drug prices for the elderly? To develop personalized medical treatments directed to our individual genetic code?
Comparative effectiveness will be attacked, sliced, diced and impaled, but the concept of medical prioritization must survive this effort. Personally, I think that physicians should spearhead this issue, but doctors would have to set self-interest aside to assume this leadership role. I hope that they will do so.
In my own family, we have limited funds to run the household. There are many activities and purchases that are beyond our means. Like every other family, we choose to pursue those that are truly essential and we can afford. Lower priority items, although desirable, are skipped. Yikes! I must be rationing with my own kids. Is there another term I could use? Comments welcome.