The New York Times' Robert Pear examines the content and contentiousness of the comparative effectiveness provisions of the $787 billion stimulus package.
HR 1 provides $1.1 billion (pdf starting on page 156) to AHRQ, NIH and the HHS to evaluate the relative effectiveness of different health care services and treatment options. The goal is to create a process of funding and disseminating comparative effectiveness research that is transparent, professional and free from conflicts of interests. As the Dartmouth Atlas' Elliott S. Fisher, MD, tells Pear, the funding would be used to try to answer questions such as:
Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of "talk therapy" and prescription drugs to treat mild depression?
It's not just the blogosphere that's agog about some of the pretty astonishing things being said about comparative effectiveness. Steven Pearlstein's Washington Post column debunks some of the wild arguments being made against the comparative effectiveness and health IT provisions in the stimulus bill. Pearlstein provides an insightful look at how the controversy got started and addresses the alarmist rhetoric. He rightly points out:
There's nothing particularly new about comparative effectiveness research—the National Institutes of Health, along with the Agency for Healthcare Research and Quality, have been doing it for years, with a budget last year of about $335 million....nearly all experts agree (comparative effectiveness research) is a necessary first step to reforming a broken health-care system.
Pearlstein punches holes in the argument that the research would lead to denial of appropriate care and makes the case that our health system would be, well, healthier if we had better information on what works and what doesn't:
Imagine plunking down more than $2 trillion a year and not knowing what you are getting for it. Imagine that what you are purchasing gets more complicated and convoluted every year. Imagine that lives, literally, hang in the balance.
Then imagine that someone comes up with a sensible approach to solving or at least shrinking the problem. And they get hit on the head for their efforts.
Welcome to the world of comparative effectiveness.
The latest installment of the New York Times "The Evidence Gap" series ran over the holiday weekend and looked at why doctors by and large kept prescribing expensive brand name blood pressure drugs years after a huge $130 million government-funded clinical trial known as Allhat showed that older generic diuretics worked better for far less money.
As the Wall Street Journal's Health Blog put it, "Study Found Cheap Blood Pressure Meds Are Best. No One Cared."
On one level, the Times article provided an illuminating look at how the losers in this study—name-brand drug companies—sowed doubt about the accuracy and reliability of the Allhat study as they increased efforts to market their drugs.
The Washington Post reviews the growing consensus and awareness about the amount of waste in our health spending. The piece includes "one small vignette" of success in what one health executive called a "mega-mess," and one note of hope that people will soon be in the right places to start fixing it.
"We're not getting what we pay for," says Denis Cortese, president and chief executive of the Mayo Clinic. "It's just that simple."
The "vignette" involves Starbucks, Aetna, and Seattle's Virginia Mason Medical Center, which as we've noted in the past has a reputation as a health-care efficiency innovator. Apparently all that coffee-pouring is hard on one's back, so Starbucks was spending big bucks on MRIs. Even though there is little scientific data that MRIs help in such cases. Ceci Connolly writes:
So they flipped the process, trying physical therapy first. To make up for some of Virginia Mason's lost revenue, Aetna increased its payment for the therapy. Today, the majority of Starbucks employees with back trouble return to work within 48 hours without an MRI or a prescription.
Lower costs. Better outcomes.
Can we interest you in some unapproved drugs?
Medicaid is interested. So is the FDA. And Senator Chuck Grassley (R-IA). It seems that from 2004 to 2007, Medicaid spent nearly $198 million paying for prescription drugs that had not gone through FDA safety and effectiveness reviews, according to analysis of federal data by the Associated Press.
Bringing in the bigger picture, the AP notes:
At a time when families, businesses and government are struggling with health care costs and 46 million people are uninsured, payments for questionable medications amount to an unplugged leak in the system.
The FDA estimates that unapproved drugs account for 2 percent of all prescriptions, or about 72 million scripts per year. (Informative FDA video with great sound track here) Many of these drugs provide little or no benefit to the patient. Some are potentially harmful, even deadly, contributing to the some 1.5 million Americans, killed sickened or harmed by preventable medication errors each year.
Months ago, in one of several posts about the daVinci Robot Surgical System,(also here and here), we wrote about Paul Levy's struggle over whether to purchase one for Beth Israel Deaconess Medical Center in Boston, where he is CEO. Levy revisited the topic in a post he called "Uncle!"
He's still not convinced whether the clinical efficiency measures up to the manufacturers' marketing efficiency, but concluded he had to surrender to the technology arms race... one reason which health costs are pushed ever higher. He wrote:
A few health tidbits in
Peter Orszag, the respected head of the Congressional Budget Office, looks likely to head up the White House Office of Budget and Management. Orszag "gets" health care, and he has been extremely effective in his two years at CBO in helping others in Washington "get" it too. He is one big reason why you hear a different dialogue around town these days, a dialogue that reflects understanding of the huge amount of waste and poor quality built into our anachronistic payment and delivery sytem. Orszag appears to live, breathe, eat and sleep Dartmouth Atlas data, and wants us to invest in comparative effectiveness research so we don't deliver and pay for care of "dubious value."
We write often about how inefficiently we provide care in the U.S., and how a top order of business for the next administration should be establishing a comparative effectiveness entity to help sort out what works and what doesn't. A story in today's New York Times about a court ruling on Medicare spending stresses the importance of having independent analysis about effectiveness.
The article reports that a Federal District Court in Washington blocked the Bush administration's effort to save money on Medicare by paying only for the least expensive treatment for a condition—in this legal case, chronic obstructionary pulmonary disease.
The administration wanted the Health and Human Services Secretary to have more discretion over Medicare payment policies. The judge said Congress sets detailed formulas.
We think this begs an important question. Do lawmakers really know whether drug A or drug B is really better for COPD? Do cabinet secretaries? The answers should rather be based on independent, reliable, untainted science and public health data. You can't make cost-benefit analysis without knowing the benefits. And if we really make an effort to get good data, to pay for effective quality care and not waste so much money on unproven or outright unnecessary care (maybe $700 to $800 billion a year), the cost piece of that equation may not be quite so daunting.
None of us need to be reminded that we live in a time when every dollar, including every health care dollar, has to count. We highly recommend a terrific New York Times op-ed today by the unlikely trio of Sen. John Kerry, former House Speaker Newt Gingrich and Oakland A's General Manager Billy Beane. They call for government-backed, truly independent comparative effectiveness program to find out what works in medicine and what we should stop wasting our money on. And remember, they penned this piece even before this week's headlines about the widespread practice of doctors prescribing placebos.