Image: Matt Collins
-
The Best Science Writing Online 2012
Showcasing more than fifty of the most provocative, original, and significant online essays from 2011, The Best Science Writing Online 2012 will change the way...
Read More »
Amid all the political battlefronts in the effort to reform our multi-trillion-dollar health care system, some of the most potentially worthwhile initiatives have received little notice—and the notice they have received has threatened to undo them. Each of the health care bills under consideration as we went to press creates a government-supported institute to oversee research comparing the effectiveness of existing medical treatments and practices. The American Recovery and Reinvestment Act of 2009 also allotted $1.1 billion to comparative effectiveness research (CER), whose results are expected to begin appearing within a year or so.
To guide the spending of that money, the National Institute of Medicine made a priority list of situations for which data about outcomes are badly needed—for instance, comparing the effectiveness of various medical and behavioral interventions to prevent the elderly from falling (the complications of which are a leading cause of death), comparing assorted drugs and surgeries alone or in combination in the treatment of specific cancers, comparing the effectiveness of different implants and devices for treating hearing loss, and so forth.* In most cases, the recommendations explicitly state the goal is to compare the effectiveness of treatments and practices in specific patient populations. In other words, not to seek one-size-fits-all answers.
Yet many people have gotten the wrong impression that CER is little more than an excuse to ration care. In early December, Senator Lisa Murkowski of Alaska attempted to insert an amendment to the health care bill forbidding insurers from denying coverage of medical tests or treatments based on comparative effectiveness research findings. She was responding to the brief but loud controversy over a study last fall that questioned the value of routine yearly mammograms for women younger than 50. A study panel appointed by the U.S. Preventive Services Task Force reviewed available evidence and concluded that a blanket recommendation for women to have annual mammograms starting at age 40 is unwarranted. By the group’s calculation, the mass screenings incurred a high likelihood of invasive follow-up testing and anxiety while finding a relatively small number of cancers that would have been lethal if they were caught later. To save 10,000 lives through early detection of tumors, one analysis found, 19 million women in their 40s would have to be screened over 10 years.
Advocates of cutting health spending did not help matters by noting that those figures could add up to $20 million per life saved. The cost-benefit discussion left the impression that the panel had judged the value of those 10,000 hypothetical women’s lives and decided that the price of saving them was too high. But the report could and should have been interpreted differently. It assessed risks, not costs, versus benefits. And it did not say that mass screening is ineffective at catching deadly cancers, merely grossly inefficient, which is as much a commentary on the inadequacies of current screening technologies as on the ineffectiveness of blanket prescriptions.
To make informed decisions, any individual and his or her doctor need evidence, so comparative effectiveness research should, in principle, make more personalized medicine possible. The goal of CER is not to identify the most effective test or therapy for the great majority and impose it on everyone. Nor is it to ration health care—if CER finds that the more expensive treatment is also the most effective, so be it.
Senator Murkowski’s amendment was ultimately defeated, but Senator Barbara Mikulski of Maryland succeeded in adding language to the bill requiring insurers to cover mammograms that doctors deem prudent, and Senator David Vitter of Louisiana added, by unanimous consent, a directive telling the government to disregard the latest task force recommendations. This fear and misunderstanding of comparative effectiveness research are unfortunate. Used properly, the CER studies should give us better medicine, not take it away. That should make support and protection for comparative effectiveness research one of the easiest pieces of the health care puzzle to resolve.
*Erratum (11/23/10): The editors referred to the National Institute of Medicine. The correct name is the Institute of Medicine of the National Academies.
Rights & Permissions
See what we're tweeting about
13 Comments
Add CommentIs this a Science site or a political site?
Reply | Report Abuse | Link to thisSciAm doesn't help the name of Science.
I've recently come across a heart surgeon in India who is taking an assembly line approach to health care and surgery. Do everything in mass and do it the same way and you can start saving money and lives because of mistakes.
Reply | Report Abuse | Link to thisIf I need a kidney transplant I should go to a facility that does only that. A facility that does the same thing day in and day out. They would see ways to improve pt care, as well as ways to save money.
Come on Henry Ford figured this out at the turn of the century, why don't we do the same now?
As medical director of two western coal companies we have created a program that has reduced our costs per employee to 56% of the 2005 values. Rather than be concerned with discounts we base our program on reducing hospital costs by paying for our employees to have complex care performed at the very best facility for that condition. A Washington, D. C. economist tried to get a grant to develop more value based programs but was told what we were doing was "too easy". The only people who have shown an interest have been the Germans who had me speak at a quality conference last November in Berlin.
Reply | Report Abuse | Link to thisAs someone who has spent time studying various health systems around the world, I can tell you there is a huge basis of reputable world health literature that demonstrates all kinds of ways that health care costs can be reduced.
Reply | Report Abuse | Link to thisThat is not the problem faced by the American (or other countries for that matter) health care. It is having in place a *system* that allows for the universal imposition of reforms and standards and review. Such systems can be accomplished through either a single payer or a free market system. The U.S. does not have such a system in place yet.
In response to 'candide' above. A science magazine *is* an appropriate place to discuss management systems, particularly if those systems are ultimately science based.
It's not always so simple to decide on best procedures, especially with mental health care. There are many studies showing CBT (cognitive behavioral therapy) to be most effective with many conditions, but that simple fact covers up huge complexities. There are even stronger studies showing that the nature of the therapeutic relationship is a much stronger predictor of efficacy than the method used. I wouldn't mind if my heart surgeon was a cold son-of-a-bitch or a really compassionate person as long as he followed the best procedure. But I would never see a cold son-of-a-bitch therapist no matter how well he knew how to use CBT. Psychodynamic therapy is much more subtle than CBT and depends much more on the nature of the relationship, and is therefore very hard to test in double-blind randomized studies. Meta-analyses have shown, however, that psychodynamic therapy works almost as well as CBT in the short term, but much better in the long term. In other words, people change in deeper ways, while with CBT the problems come back. So the cheaper, more empirically-based, more "effective" method isn't what it looks like on the surface. The tendency to back CBT as more evidence-based is, in fact, an attempt to ration care that takes longer, is more expensive, requires better-trained clinicians, and works way more effectively.
Reply | Report Abuse | Link to thisThe polititians need to back out of reforming our health care system and take their special interests and lobbyists with them. The health care system should be just that, a system. Health care needs to be addressed as an engineering problem applying the same kind of analysis as one would any other complex problem.
Reply | Report Abuse | Link to thisWe should start with the simplest, most pressing problems and gradually add elements with more unknowns to the equation. The system won't be perfect from the start and may never be perfect but it will beat the hell out of what we have now. As Bill Case alludes there are a lot more solutions in the world than just Canada or the UK. A lot of this is not rocket science.
I am not a researcher, just a retired clinician who was hired to lower cost quickly or significant restructuring of benefits would occur. I wasn't smart enough to know the task was impossible. The urgency carried the caveat something had to be implemented soon. The result was a simple but effective program. I have attended many symposia on care since I started this in 2001. Unfortunately the presentations are academic with very few out there doing anything.
It is time to implement thoughtful solutions and save the retoric for the next levels of complexity. Let us start helping patients (consumers, a word I hate) purchase value based care. No citizen of an affluent, modern nation should lack access to even the most basic healthcare nor should be cost be prohibitive.
Of course science is a good way to optimize health care. Science is simply a feedback mechanism to get the best results. It is already being used in health care. The problem is the definition of "best". For the patient it is simply minimizing suffering. But for the for-profit companies providing and financing health care, best means maximum profits. Which does not necessarily give the best from the patient point of view. Since the money guys are the ones giving feedback (in the form of $$$) to the politicians, guess which form of "best" is going to be legislated?
Reply | Report Abuse | Link to thisThe utility of a suumative assessment is shaped as much by socio-political factors as by scientific concerns. Historically, programs have been eliminated b/c a study shows performance fails to meet a funders' expectations, which may not be grounded in altruistic values. My question is whether there is any evidence showing such studies increase the likelihhood of providing more effective and meaninful care to the public
Reply | Report Abuse | Link to thisSome remarks on comments made here. dfcrowder sugests that "The polititians need to back out of reforming our health care system and take their special interests and lobbyists with them." That is wishful thinking. Besides, the establishment of a framework for health care reform has to be put in place before effective reforms can be insituted. Creating the frame work has to be a political decision. Why it has to be political would take pages to argue, but let it simply be said no overarching health care system in the world today was implemented without first taking the political decision to do so.
Reply | Report Abuse | Link to thisIn response to joeldooris and rajahornstein, most health care systems that already exist are fexible enough to accomodate standards, checklists *and* creative practicing.
One major point that is overlooked by all paricipants in the American health care debate is that once health care enters the public arena, it stays in the public arena. I don't think American national politicans or special interest advocates (left or right) have a full understanding of how much of their political lives are going to be taken up by one health care issue after another -- and scientests will never be able to free themselves from the public debate.
You are of course correct. However the influential input has come from those who will be financially rewarded such as providers and big Pharma not to mention those who view reform as "socialized medicine", a much greater threat than folks dying because of not being able to access care. Sometimes idealism gets the best of me and I think of congress as a rational body.
Reply | Report Abuse | Link to thisThe group with a weak voice but potentially a big stick has been industry not affiliated with health, yet this group is the source of the money for care. Senior management pays lip service to cost but generally leaves the solutions to human resources. Companies prefer to lobby only about core interests. This philosophy feeds back to the first paragraph.
My companies have the resources to create internal solutions rather than simply accept the status quo. Unfortunately the average person does not have this choice.
Michael Porter at the Harvard Business School has written extensively about value based healthcare. The most concise publication of his was an article from the Harvard Business Review in 2004. T. R. Reid, a NYT Journalist has written a good survey book on systems of care around the world entitled "The Healing of America".
You have hit upon something in your second paragraph that as a Canadian I don't understand. I have seen in interviews over that last four or five years, the CEOs of GM, GE, Xerox and many other major firms, complain about the cost of health care. They have complained about the damage the current burden of Employee Health Insurance, legacy health insurance and the international competitive disadvantage that providing Insurance puts on them. Yet they are all absent from the current debate. Why?
Reply | Report Abuse | Link to thishi rajahornstein, could you provide links to the meta-anayses you mention, i'd be interested to follow these up, thanks.
Reply | Report Abuse | Link to thisThank you, editors of SA, for spotlighting the potential of CER. We feel compelled to note the contribution of Dr. John Wennberg, his early work in pioneering the first CER database, enhanced by his continuing involvement with The Dartmouth Atlas.
Reply | Report Abuse | Link to thisHis early scientific work on unwarranted variation has been the progenitor of political interest in CER. Informed patient decision-making based on Wennbergs data led to one of the fastest growing for-profit healthcare management companies, Health Dialog <http://www.healthdialog.com> . HD has indisputably proven that the practical application of CER delivers positive simultaneous outcomes on both patient satisfaction and cost reduction scales - -and we are proud of that.
Our Spencer Trask investor network <http://www.spencertrask.com> were the angel investors for Health Dialog, and the company has delivered infinite returns to investors, insurers and patients alike.