Sunday, May 10, 2009

Comparative Effectiveness: Sound Policy or Socialized Medicine?

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.


  1. Microvolt t-wave alternans is a perfect example of why and how we've reached this point in healthcare.

    with a 98% negative predictive value in study after study, it has been buried and trashed by the ICD industry and the HRS after one unbelievably flawed and biased study two years ago.

    There is no argument that more than one third of the patients that recieve an ICD will never benefit from it, but current guidelines suggest any patient with an ejection fraction below 35 should be considered a candidate for the 30,000.00 ICD.

    Most patients, given the choice of an additional, 250 dollar, non-invasive test with a 98% negative predictive value, would choose that test over the invasive EP test and unnecessary ICD.

    Review paper from Dr Theodore Chow( PI of Master Study)

    Expert Commentary from T. Chow paper:

    “The weight of the literature suggests that MTWA is a powerful predictor of total and arrhythmic mortality – but not ICD shocks. As such, it provides the clinician additional information that helps them make rational decisions about ICD therapy. MTWA does not replace ICD treatment guidelines, but complements it. In my opinion, MTWA is most useful today in determining what to do with borderline indicated patients, or those with a shortened time frame for ICD benefit due to co-morbid illness or advanced age. It is a good practical tool to introduce the topic of SCD risk to the stable patient, or reinforce the risk lurking beneath the surface to the reluctant patient. MTWA as a risk stratifier sits somewhere between cholesterol – where firm guidelines and treatment algorithms exist – and inflammatory biomarkers – which are nonspecific and not required, but potentially useful for the thoughtful physician. MTWA is physiologically linked to ventricular arrhythmias, and should be considered an additional tool in assessing the patient whose risk for SCD needs further clarification. How often this occurs practically is dependent upon practice style – it will be less useful for aggressive physicians who generally implant without consideration to risk stratification, but more useful for the majority of physicians who already practice ICD risk stratification, even though it is not commonly referred to as such. For these physicians, MTWA provides a method for more accurately tailoring treatment to the individual patient.”

    “In an era of ever-declining physician reimbursement there are always concerns that additional testing might reduce implant rates, further lowering physician income. Since no studies exist on this topic, I can only cite extensive personal experience and observation of others who have used this technology to conclude that the effect of MTWA on the ‘business’ aspect of medicine is entirely related to how it is deployed. If one uses it to restrict devices, that it what will happen. If one uses it to recruit marginal increases in implants through improved patient and physician acceptance of ICD need, this is what will happen. In this respect, MTWA does what is asked of it.”

  2. I appreciate your thoughtful comments. I am sure that every medical specialty can offer similar anecdotes of medical interventions that are not clearly indicated or could have been substituted by a less invasive or less expensive alternative. Comparative effectiveness research, if it ever gets airborne, will meet explosive resistance from the various constituencies who will be at risk.

  3. Dr. Kirsch,
    I will start by agreeing with the premise that there is a great deal of waste in unnecessary and potentially harmful diagnostics and treatments. Further, I agree that the scientific process helps us differentiate those interventions that are beneficial from those that are not.
    Where I disagree is in how we use this information. Do we not believe that physicians are capable of understanding and utilizing the results of CE as they counsel their patients? Who constitutes the "we" that determines what to do with the "savings" from cost shifting that will result from compulsory implementation of treatment algorithms?
    While I agree that Americans have an insatiable appetite for medical care, I think this is only a bad thing when patients are not the ones responsible for this cost. Increased data on cost effectiveness, coupled with a return of autonomy to patients and their physicians, would do much to reduce health care costs for patients (medicalese for 'consumers'). Then, we suddenly become as distressed about rising costs in health care as we are about rising costs in cell phone usage or automobiles or trips to theme parks.
    It is the duty of physicians to implement the findings of CE in the service of their patients, and this is what will drive improved outcomes, with cost savings as a byproduct.

  4. It appears that we largely agree. I believe that we physicians already have sufficient knowledge and judgment to utilize comparative effectiveness in our practices. Often, we choose not do so. You may visit a prior posting on this blog entitled, Understanding the CAT Scan Cascade, which highlights many reasons phyicians order these scans. Additionally, I agree that when patients bear little financial responsbility for their care, we forfeit an important brake on the system. We have to be cautious as we do not want an individual to be denied truly necessary care because of cost. However,if patients had more of a financial stake, they would question their doctors more thoroughly about their medical recommendations. It's always easier to spend someone else's money. These issues are extremely complex and no simple solutions are forthcoming.

  5. I would have copied more but below are statistics people are reading online.

    America dosen't look like it has the best health care
    in the world.

    1 France
    2 Italy
    3 San Marino
    4 Andorra
    5 Malta
    6 Singapore
    7 Spain
    8 Oman
    9 Austria
    10 Japan
    11 Norway
    12 Portugal
    13 Monaco
    14 Greece
    15 Iceland
    16 Luxembourg
    17 Netherlands
    18 United Kingdom
    19 Ireland
    20 Switzerland
    21 Belgium
    22 Colombia
    23 Sweden
    24 Cyprus
    25 Germany
    26 Saudi Arabia
    27 United Arab Emirates
    28 Israel
    29 Morocco
    30 Canada
    31 Finland
    32 Australia
    33 Chile
    34 Denmark
    35 Dominica
    36 Costa Rica
    37 United States of America
    38 Slovenia
    39 Cuba
    40 Brunei