Comparative Effectiveness Research
Email This Post
Print This Post
I was one of several local (aka, “Boston area”) health care participants who had a chance to hear Dr. Steve Pearson, President of the Institute for Clinical and Economic Review and Senior Fellow at America’s Health Insurance Plans in Washington, DC speak recently about “CER” (Comparative Effectiveness Research). I’m proud to say that Dr. Pearson is a member of the faculty at the Department of Ambulatory Care and Prevention at the Harvard Medical School — and is, therefore, supported in part by the folks at Harvard Pilgrim Health Care — who support the DACP at HMS as a joint venture with the medical school.
Dr. Pearson is the Vice-Chair of the Medicare Evidence Development and Coverage Advisory Committee, serves as a member of the AcademyHealth Methods Council, and also serves on the management committee of the International Society on Priorities in Health Care. In 2004 he was awarded an Atlantic Fellowship to pursue policy studies at the National Institute for Health and Clinical Excellence (NICE) in London, England. He returned to the US to serve from 2005-2006 as Special Advisor, Technology and Coverage Policy, at the Centers for Medicare and Medicaid Services. In 2006, he founded the Institute for Clinical and Economic Review (ICER). ICER produces appraisals of the clinical effectiveness and cost-effectiveness of medical innovations, with the goal of providing new information to decision makers intent on improving the value of health care services.
I mention all this to simply point out the guy’s got the tickets to talk about this subject, and he did so — with gusto — at this meeting. Thanks to the folks from The Heller School at Brandeis for putting the presentation together, and to Partners HealthCare, Blue Cross/Blue Shield of MA, and the Greater Boston Chamber of Commerce for sponsoring the discussion.
Whew. Sorry for the lengthy intro. Steve began by describing two kinds of effectiveness research. One way studies treatments to determine if they are/can be/will be effective in combating an ailment or an illness. The other way studies cost-effectiveness — or which approach is likely to do more for less, which he described as a tougher question to answer. In England, NICE, not surprisingly, studies the latter issue — and if they determine something’s not cost-effective (although it might be clinically effective), they don’t pay for it. So if a new drug becomes available to treat some disease or illness — but it’s not that much better than the existing drugs — and it costs a lot more — NICE would not recommend covering it.
This stands in deep contrast to the way we work in the U.S. In fact, the Federal Drug Administration isn’t allowed — under federal law — to consider cost-effectiveness when it reviews the clinical capabilities of new drugs. It can only consider whether or not they work — not whether or not they’re cheaper/the same as existing alternatives. Pretty different.
Steve does do cost-benefit analysis, and used as one of his examples a study his group did on the cost-effectiveness of IMRT (Intensity Modulated Radiation Therapy — new way) vs. 3D-CRT (3-dimensional conformal radiation therapy — old way) for treating prostate cancer. The old way does lead, on occasion, to proctitis (bowel inflammation) in some patients, while the new way can reduce the likelihood of this side effect. Proctitis is uncomfortable, but pretty treatable, and certainly not life threatening.
That makes it clinically more effective — but does it make it more cost-effective?
As is often the case, Medicare likes the “new way” better than the “old way” and pays $42,000 a pop for IMRT, but only $10,000 for 3D-CRT. Not to rag on Medicare — but does this seem surprising to anyone? Anyway, guess which way we treat prostate cancer in the U.S.? The Health Care Quality and Cost Council in Massachusetts says IMRT finishes 9th on its list of the most used/expensive outpatient procedures in Massachusetts.
Steve’s group took a pretty deep look at whether the additional cost of IMRT was worth the benefit of reducing some proctitis cases in some patients. They concluded that the cost to Medicare of preventing one case of proctitis was $300,000. I would note here that this number would work for almost of us in health care, too — since we usually use Medicare fee schedules as our baseline for payment as well.
So from Steve’s point of view, it would be very, very hard to argue that this new way is cost effective, relative to the old way — given the very high cost of preventing a treatable, manageable side effect of prostate cancer treatment. But we use it. A lot.
We need more analysis like this about health care in this country. Our system is more technologically sophisticated than it’s ever been before, our costs are higher than they’ve ever been before, and other countries are leading the charge in this area, while we watch. This makes no sense to me at all. I would much rather spend more money on things that make sense and are cost-effective, and less on things that aren’t than the other way around. Right now, we seemed destined to do the latter.
I agree that it would be very helpful if we had good, objective comparative effectiveness research that analyzed the cost-effectiveness of both existing and new treatments including drugs and devices. The challenges, I think, relate to both funding (how much is enough and who pays) and maintaining the political independence of the agency or group charged with performing the research and reaching the conclusions.
Some have suggested modeling a comparative effectiveness research agency after the Federal Reserve Board which sounds good in theory. However, as Alan Greenspan points out in his recent book “The Age of Turbulence,” the Fed has about 2,000 employees, a budget of $300 million per year and it’s own funding source from interest on government securities it owns and lending to banks as well as profits from buying and selling government securities. There will always be heavy pushback from providers who may lose business when their treatments are either not covered by payers or deemed to be less cost-effective than alternatives.
I also think that it might be helpful if insurers were not quite as rigidly tied to Medicare in setting fee schedules. If, for example, insurers think that Medicare pays too little for primary care, which could help to keep people healthy, or palliative care, which could reduce healthcare utilization at the end of life, they should be willing to pay considerably more than Medicare if necessary to insure adequate availability of these services which could save money overall for both the system generally and the insurers specifically.
Cost Effectiveness Research and Evidence Based Medicine are terms which sound great, and Steve does good work in this area, but payers have been known to apply these terms to rationing practices designed solely to reduce their spending. I have written about this on my blog (healthpolcom.com/blog) and encountered it frequently when researching the Veterans’ health system’s practices. The other challenge in CER research is how it asks the question about value (or cost-effectiveness) to whom? The same data can provide very different answers when applied to the payer, the employer, the patient or society overall.
I agree with Barry, “The challenges, I think, relate to both funding (how much is enough and who pays) and maintaining the political independence of the agency or group charged with performing the research and reaching the conclusions.”
But I ask, what about research that leads to proven treatments? Even when the treatments are validated and proven, the payment of such services can often fall upon the patient due to miscommunication of what is covered between the the Service Provider and the Health Care provider.
Why must the responibility of facilitating clear communication between these groups fall upon the patient. They are the only ones that end up suffering.