02 March 2009


And so it begins, in earnest.   A few weeks ago, it was Betsy McCaughey's op-ed, falsely claiming that the NCHIT office would force doctors to provide only approved medical care, that got wide play in the zombie right-wing press.   Today, there is this headline in the Boston Globe:

US system to rate health therapies
Critics fear plan may lead to rationing

I have to concede that this headline is perfectly accurate, though I would say that the conservative opponents of health care reform are afraid of so many things that the sub-title could as accurately read, "Critics fear plan may lead to single payer," or "Critics fear plan may lead to socialized medicine," or "Critics fear plan may lead to the END of AMERICA as we KNOW IT!"  So I would take the bogeymen of the right wing with the proverbial grain of salt.

What they are raving about is "Comparative effectiveness research," or CER, in which various therapies are compared against one another to see which works better.   It sounds simple and inoffensive enough, doesn't it?  Isn't that the whole point of science and evidence-based medicine -- to conduct experiments and use them to guide medical decision-making?

Yes, but, if you are an lobby with an interest to defend, say you make a large number of expensive drugs or implantable devices which may or may not be more effective than pre-existing, cheaper products, you have a powerful interest in protecting your bottom line by blocking or discrediting CER.   And if you are a political opportunist opposed to Obama's health care reforms for ideological reasons, then this is an easy chance to frighten away support for reform by screaming "rationing!"

Just for the record, if, as the sober-eyed "health economist for the conservative Heritage Foundation" gravely warns, this does result in "restricting treatment options based on a government-run board's interpretations of research," it is important to understand: that is not what rationing is.

Rationing is generally understood to mean the practice of restricting allotments of resources due to scarcity.   As applied to health care, this generally means that certain therapies are not covered, or that only a fixed number of persons are allowed to get them.   Think of waiting lines for knee replacements, or managed care plans who refused to cover bone marrow transplants for breast cancer (which, ironically, were not effective any way).   That's rationing.

It is something of a sad statement on the bizarre poltical world we are about to enter that people can posit things such as "care that is not deemed most effective should be covered" and "research should not determine whether procedures or drugs will be paid for" and still be taken as serious, rational, good-faith participants in the debate.   Of course if there are therapies which are ineffective, we should stop paying for them!  Of course if there are comparably effective therapies, the cheaper one should be favored!  Anybody who cannot agree with simple principles like these is either stupid or corrupt.

My point, however, is that, if this came to pass, if there were some "government board" arbitrating the efficacy of competing therapies based on CER (which there is not, and no proposal to create), that is still not rationing!   It is evidence-based medicine, writ large across a health system.

A health system, I hasten to add, that is consuming 17% of the GDP, and increasing in size year after year.

So it would not necessarily be a bad thing, implemented properly, to have guidelines based on good research showing clearly which treatments work better, and are cheaper.   And I will agree in advance with the inevitable commenters that a restrictive, inflexible, heavy-handed managed care approach to cutting off less-effective or more-expensive treatments would be a bad thing.  But I can imagine market-driven incentives, as outlined in the linked article, that might work well, such as " a tiered system that requires patients to pay more for treatments that are seen as less cost-effective."  Imagine that -- care which is more effective, and costs less.


Anonymous said...

You missed an important word. Lead to rationing.

Implying we don't already have rationing, like when you are denied by your insurance company. Or, economic rationing for those who can't afford health care.

Yes, if you can pay cash for something there is not rationing, but I am pretty sure any health care reform applied to the US, even single payer would not preclude some one from paying out the nose for whatever procedure they wanted.

wrin said...

Evidence based medicine is a large driver behind what should be funded and what shouldn't. Provisions of course should be made for perhaps more cutting-edge therapies with limited applications in the general population, which are less cost effective but which lead to improved outcomes in selected patients.

Discouraging evidence-based practise just makes me angry. Research is one way the health system can do work on the behalf of americans. Squelching it is anathema to me.

Simons said...

Medicine has come to this very least mainly by the bad services that we believe and trust that will be necessary and appropriate solutions to improve circumstantially.

Sun Tzu said...

NCHIT is the British NICE system, and it clearly has lead to rationing.

shadowfax said...

Sun Tzu (Great name, BTW),

NCHIT, if you bothered to read the legislation or any reliable background information, was created by President Bush in 2005 or so, and is concerned largely with setting interoperability standards for EMRs. It is not involved with CER; there were dollars for CER authorized in the stimulus, but they were divided between the NIH, CMS, and (I think) AHRQ.

The NICE comparison to NCHIT is completely fatuous.

scalpel said...

"But I can imagine market-driven incentives, as outlined in the linked article, that might work well, such as a tiered system that requires patients to pay more for treatments that are seen as less cost-effective."

That still is a form of rationing (by ability to pay), and is exactly what many insurers already are doing with their tiers of medications. If I recall, we already had a boisterous discussion about that with many rationees complaining about the "unfairness" of it all.

caroline said...

I thought you might be interested in "sitting in on" a panel discussion on CER that was held last week in Baltimore. there's a video of the meeting here:


Feel free to pass it along to colleagues who may be interested, and by all means leave your thoughts.