Questioning Effectiveness

To save both lives and money, most countries with single payer health care systems support, or at least monitor, research on the cost-effectiveness of drugs and medical procedures. One of the less well known provisions of the Affordable Care Act is a plan to support comparative effectiveness research. The bill creates a Patient-Centered Outcomes Research Institute, a nonprofit organization charged with conducting research on the comparative cost-effectiveness of various medical treatments and making recommendations to health care providers.

An Associated Press article reports that, beginning in 2012, the government will collect a fee of $1 per person from health insurance companies to cover the cost of the new agency. The fee goes up to $2 in 2013, and rises with the inflation rate in subsequent years.

I can remember a time when virtually everyone agreed that program evaluation—now called comparative effectiveness research—was an important scientific endeavor. Why should anyone suffer through and pay for a drug or medical treatment that doesn't work?  If two treatments are equal in effectiveness, shouldn't only the cheaper one be covered by insurance? By coincidence, today's newspaper has two articles implying that current evaluation research is inadequate. All-metal hip replacement implants are breaking down after a few years, causing endless suffering to those who have received them. And Chantix, a quit-smoking drug that is only slightly better than a placebo, apparently has adverse side effects that include violence, depression and suicide. (“The good news, Mrs. Obama, is that your husband has quit smoking . . .”)

But the consensus over evaluation research began to break down when American corporations and their friends in the Elephant Party declared “war on science.” Although its origins can be traced to the 1960s “debate” over the health effects of cigarette smoking, the war began in earnest about a decade ago. As a result, many Americans believe that scientific research is inevitably biased, that scientists discover non-existent problems just to supplement their incomes, and that the consensus conclusions of experts are just another opinion, no better or no worse than, say, Rush Limbaugh's opinion.

Combine this with a distrust of government and you get claims like that of the Elephant beauty queen Sarah Palin that the Jackass Party is trying to set up “death panels” to ration medical care. (Yes, Gov. Palin, health care is being rationed, but not by the government.) In the current political environment, there is a very real possibility that this new agency's research will be wasted because every conclusion it draws will be endlessly disputed.

A second problem is evident in the Elephant-friendly way the AP article presents the fee—as a tax. Obviously, the research institute has to be funded. But couldn't the Obama administration have found a way to pay for it out of general revenue, without making the source of funding so explicit and obvious? You can bet the insurance companies will publicize this fee for all it's worth, hoping to get consumers to blame their next $1000/year rate increase on the government's $1/year “tax increase.”

Gail Wilensky, a former Medicare administrator who supports the agency, is paraphrased in the article as saying that it “should focus on high cost procedures and drugs on which the medical community has not developed a consensus.” I disagree. The most important thing to do is to support research with maximum potential for saving lives. By emphasizing the cost-cutting implication of their research, Ms. Wilensky probably hopes to keep the agency from being trampled by a bewildered herd of Elephants. But you can't pacify this species. If you try to save money, you will almost certainly be accused of rationing care.

One of my resolutions for 2012 is to do an occasional series of posts on the values and pitfalls of health care evaluation research.