Comparative effectiveness research (CER) needs honest discussion

Comparative effectiveness research (CER) is suddenly a hot topic at all the health care conferences.

How come? Everybody agrees that we have to decrease per-capita cost and increase quality. Why? Government programs like Medicare and Medicaid foot more than 50% of our nation’s health bill, and if everything stays the same these programs will go belly up (bankrupt) in 8 years. Big problem.

Health and Human Services (HHS) has defined comparative effectiveness research as conducting and synthesizing research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in “real world” settings. In other words, CER is figuring out what treatments, tests, and drugs work and which ones don’t work.

John E. Wennberg spent a whole career at Dartmouth studying American medicine, and he comes to the startling conclusion that 60% of Medicare is spent on supply sensitive care (physician visits, consultations, imaging exams, and hospital and ICU admissions) and 25% on preference sensitive care (PSA tests, mammography, and elective surgery). Although we assume that this care is based on solid scientific evidence, Wennberg states that “medical science is virtually silent on such matters” as how often to see a patient, what test to order, and whether to admit a patient to the hospital or ICU. Some evidence based medicine experts state that only about 20% of what physicians do is based on sound science.

The American Recovery and Reinvestment Act of 2009 contained $1.1 billion for CER, and the Patient Protection and Affordable Care Act of 2010 put in place a structure including a Patient-Centered Outcomes Research Institute to provide a continuous stream of funding and oversight to CER.

So we just need to do the research, figure out what works, and then have Medicare only pay for treatments and tests that work. That approach will solve the health care budget crisis and pay for care that is evidence-based. Right? Wrong. In the current legislation is language that states that CER findings may not be “construed” as mandates regarding payment or treatment or to deny or ration care.

A quick history of CER in the United States reveals how intense the politics around health care can become. Senator David Durenberger of Minnesota in the 1990s encouraged the government to fund Patient Outcomes Research Teams (PORT) to study the best ways to treat angina, low back pain, cataracts, and benign prostatic hypertrophy. When the 23 member expert PORT panel found little science to support surgery as a first line treatment for low back pain, the back surgeons lobbied Congress. The result was Congress cut CER funding for the PORT; one man’s waste is another man’s revenue.

One way to analyze the intensity of health care in the United States is to take a look at Medicare data for the last two years of life. The Dartmouth Atlas project that Wennberg founded had done just that. In the last two years of life, per-capita Medicare spending at UCLA is $93,842 per patient and $53,432 per patient at the Mayo Clinic. Many have suggested if we could get the entire country to treat such patients like the Mayo Clinic we could save $700 billion a year. Another study looking at the last two years of life found that patients in Newark, New Jersey spend about 35 days in the hospital; patients in Cleveland and San Francisco spend about 20 days in the hospital; and patients in Portland, Oregon, and Salt Lake City, Utah spend only 12 days in the hospital. If the doctors in Portland and Salt Lake City could teach the rest of us how they do it, much of our budget problems would be gone.

If CER is just trying to figure out what is scientifically the best way to diagnose and treat human disease how can anyone be against it?

Princeton health care economist Uwe Reinhardt writing in the New York Times economics blog identifies two groups opposing CER:

“The first group includes individuals or enterprises that book other people’s health care spending as their own health care income.”

“The second group … includes individuals who sincerely believe that health and life are ‘priceless’ – for them cost should never be allowed to enter clinical decisions.”

What seems clear is that American society needs to have a frank and honest discussion about CER, waste, and the American budget deficits. CER itself is not controversial. It is what you do with the results that create political tension and heat. The Kaiser Family Foundation stated the obvious when they wrote recently: “Ultimately, however, conducting research and gaining knowledge about what is clinically effective is only valuable if the findings are used by the health care system.”