Comparative Effectiveness (Part II)
Powerful forces continue to propel our nation health care costs upward. One such force is the unrealistic expectations – we often expect too much from our health care system. The increasing attention given to medical and healthcare issues by our society today has contributed to an increased the number of people reporting serious healthcare episodes from .82 in 1920 to 2.12 in 1980. We find it easier to depend on the healers rather than do the things that we know will prevent illness. This attitude is firmly entrenched and has helped lead to an explosion in health care costs.
In addition, a further factor in the increasing health cost dilemma is the fact that health care costs and utilization differ markedly across the country. For example, one study showed that in the last 2 years of life patients used 10.6 hospital patient days in Bend, Oregon compared to 34.9 days in New York City. In the last 6 months of life patients visited a doctor 15.5 times in Ogden, Utah and 59.2 times in Los Angeles. Further, a recent study in the Journal of Health Affairs found that more intense and costly care does not necessarily provide better quality treatment. How can we address this dilemma and develop better decision making tools for patients and providers? On what basis can we change our reimbursement systems from payment for expensive procedures and services to payment for value and wellness?
One tool that addresses these issues is Comparative Effectiveness Research (CER). A Federal Coordinating Counsel for Comparative Effectiveness Research has been created as part of the recently passed stimulus bill and the new budget allocates over one billion dollars to fund CER. The goal of CER is to provide tools for better decision making by patients and providers. The Institute of Medicine clearly explains the concept. The medical field is founded upon an inherent trust placed by the patient in their doctor. Often the doctor and the patient must make decisions in the absence of complete information. CER offers the opportunity to address these challenges by demonstrating the effectiveness of one strategy over the other for a certain condition. This results in the ability of patients and doctors to make smart health decisions founded on sound scientific evidence. One of the goals of CER is to help doctors avoid ineffective or more costly approaches that might not work or, worse allow a patients’ condition to deteriorate by delaying more effective treatment.
There are many reasons that explain these differences in health care costs and utilization throughout the country. It has been suggested in a report by the Congressional Budget Office that by using the results of CER, Medicare spending--and perhaps all spending in the country--could be cut by about 30% if the more conservative practice style used in the lowest spending one-fifth of the country could be adopted nation wide. Other estimates offered are much less; however, most everyone agrees that by utilizing CER we could reduce unnecessary health care costs and utilization significantly. The growing trend toward high deductible health insurance that is coupled with an Health Care Savings would be greatly enhanced and would be a complement to CER.
A common criticism of CER is that it will become a back door leading to rationing health care. The outrageous spending on Medicare and the health care system in general would be a driving force that would promote it. It is also feared by many that this could possibly lead to euthanasia. CER without proper safeguards of patient and physician involvement should not be the final basis for determining proper medical treatment.
The ethical issues of any limits placed on healthcare services are very complex. Pope John Paul II in his “Evangelum Vitae” stated that we must never give in to the culture of death. However, he also stated that “life does not require using every available means to postpone death but what is always wrong is direct and intentional killing.” John Frame, a professor at Reformed Theological Seminary in Orlando, Florida writes that “we can let a patient die when we lack in some way the resources to save his life, whether they are time, technology, or skill. Steven Suits MD states in the current issue of The Religion and Society Report that “Clinical guidelines that are evidence based can be endorsed by the physician as fiduciary, but they must never become rigid rules that allow for the disregard of the individual patient.”
The ethical use of CER will be necessary if we are to retain the excellent distinctive of our current system. Current reform proposals are being hotly debated in Washington. However, there is already significant funding for CER and our complex health care system is already scheduled for significant change. Any utilization of CER must maintain the central role of the physician, and insure the patient is at the heart of health care. We must make sure that CER will not become politicized and that a permanent bureaucracy not be allowed to prescribe patient care. Unfortunately, we are dependent on the stated objectives of CER by Washington. Hopefully there will be an improvement in the ability to match words and actions. Life is full of trade-offs and hopefully CER will be a positive tool that will become available to all of us as we approach the end of life here on earth.