Not ‘death panel,’ but better, cheaper health care

Market Watch

Nov. 11, 2010, 12:01 a.m. EST

Not ‘death panel,’ but better, cheaper health care
‘Comparative effectiveness research’ is here: what does it mean for you?

By Anya Martin, MarketWatch

DECATUR, Ga. — A national push to increase research to find out which medical treatments work best for which patients is gaining momentum even though many worry the findings may be used to ration care.

Sixty-six percent of Americans say they support using “comparative effectiveness research,” or CER, to provide information about whether a given treatment works better than alternative ways of treating patients with the same condition, according to a recent national survey in the October issue of Health Affairs, a prominent public-policy journal.
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But 75% are convinced the government and insurance companies will use treatment guidelines derived from such studies to control costs and ration care.

In light of that public distrust — and angry protests about “death panels” — Congress included strict rules in the health-reform law stipulating that federally-funded CER results could not be used by Medicare to set pricing or limit coverage of a service. The law also provided for the formation of the Patient-Centered Outcomes Research Institute (PCORI), which will oversee CER funding and guard against ethical breaches.

National public-health experts say CER’s potential to improve health-care quality for both patients and doctors outweighs any risks, and federal money is necessary to encourage providers to take part.

A lack of understanding is behind the fear of CER, said Lou Garrison, a health economist at the University of Washington in Seattle. The safeguards in place set a high level of ethical standards, he said.

CER differs from usual clinical-trial research in that it compares the effectiveness of two or more treatments, such as two different medications or a medication and some other therapy, in a real-world environment, such as among patients at a clinic, he said.
Not about limiting choice

Under the health-reform law, federally funded CER will explore which treatments work better for specific patient populations, and it cannot be used to withhold care from any patient, said Steven Lipstein, newly appointed vice chair of PCORI’s board of directors.

That is, done correctly, CER leads not to “one-size-fits-all” medicine but more personalized care, he said.

‘Many times we don’t have any information on how to use even the simplest medical intervention.”

—Steven Lipstein, newly appointed vice chair of PCORI’s board of directors

“Every patient wants the best possible outcome and what CER is about is sharing information about what we know works well and for whom it works well and making sure patients have as much information as they can about their choices,” Lipstein said. “The sum is that CER is not about limiting choices; it’s about informing choices.”

For an example of how CER can benefit patients, imagine that you have sprained your ankle and want to reduce the swelling and speed up healing, Garrison said.

“You want to know whether anyone has done any research on how long and how frequently to place ice on it,” he said. “It seems very mundane, but many times we don’t have any information on how to use even the simplest medical intervention.”

On a larger scale, one CER project will link treatment and claims information for thousands of patients seen by six of the nation’s largest children’s health-care systems.

“Building this resource has the potential to answer hundreds of questions facing pediatricians and families, such as what is the best treatment for complicated pneumonia, skin infections, or caring for children with special health-care needs with severe reflux,” said Patrick Conway, a pediatrician at Cincinnati Children’s Hospital in Ohio, one of the participating systems.

Previous pediatric comparative outcome studies have looked at very small numbers of children, often less than 50, he said. Currently a pediatrician can learn from claims data whether a patient was admitted for pneumonia and their length of hospital stay, but would have no way to compare whether children whose pneumonia was caused by the same organism or who had similar chest X-ray results benefitted more from antibiotics or surgery to drain the infection, for example, Conway said.

The children’s treatment study received its funding from $1.1 billion in taxpayer money targeted at CER in the federal stimulus bill.

PCORI replaces the previous Federal Coordinating Council for Comparative Effectiveness Research whose members were appointed by the secretary of the Department of Health and Human Services.

In contrast, PCORI has been set up to function not as a government agency but an independent entity appointed by the nonpartisan U.S. Government Accountability Office. Its members include doctors, health administrators, representatives of nonprofit advocacy groups, and leaders from the pharmaceutical, health technology and other health-related industries.

“The people that serve on [PCORI’s] board are not employees of the federal government and broadly represent different backgrounds, experiences and parts of the country,” said Lipstein, who is also president and chief executive of St. Louis, Mo.-based BJC Health Care.
Federal funding

Congress set up a trust fund to support PCORI’s daily costs and research through 2019. This year, it will have a start-up budget of $10 million, which rises to $50 million in 2011 and $150 million in 2012.

Beginning in 2013, PCORI funding will jump to at least $620 million, supported by a $2 annual fee collected per Medicare beneficiary and private health-insurance recipient.

Ultimately, whether Americans will support this level of federal funding for CER will hinge on how the research findings are used by policymakers, said Eric M. Patashnik, professor of politics and public policy at the University of Virginia in Charlottesville and a co-researcher on the national study on public attitudes towards research-based treatment guidelines.

The survey found that 83% of Americans currently are firmly opposed to limiting the ability of their doctor to prescribe the treatment he feels is best for them, he said.

“Our research suggests that most of the public will defer to their doctor, which may reflect the public’s strong belief that CER should not interfere with the relationship between doctors and patients,” Patashnik said.

These strong public attitudes make it unlikely that Congress will change the law to allow Medicare to use CER findings to set reimbursement rates any time soon, said Steven D. Pearson, president of the Institute for Clinical and Economic Review in Boston.

However, skyrocketing health-care costs ultimately suggest that ways must be found to bring down expenditures, he added.

And consumers might be more uncomfortable that Medicare and insurers now are making coverage decisions without taking into consideration what treatments generate better patient outcomes, said Pearson, who coauthored a Health Affairs article on a common-sense way to use CER.

“This is not meant to be a silver bullet,” Pearson said, “but one small set of ideas that can hopefully lead us to a more honest dialogue down the road of what we can do to improve our health care in the long run.”

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