Myth 5. Cost control and quality will emerge from comparative effectiveness research.

Congress appropriated $1.1 billion—the total worth of 1,100 millionaires—to “comparative effectiveness research” (CER). It promised that CER would not turn out to be “cost-effectiveness research”—and the rationale for treatment rationing and denial—although it defeated a proposed amendment that would have codified that promise into law.

In his talk to the AMA, Obama said, “[We]…need to do…figure out what works, and encourage rapid implementation of what works into your practices. That’s why we are making a major investment in research to identify the best treatments for a variety of ailments and conditions.” He wants a system “where…doctors can pull up on a computer all the medical information and latest research they’d ever want to meet that patient’s needs.”

Unlike other research funded by the $30 billion spent annually by the National Institutes of Health (NIH), or by pharmaceutical companies, universities, and others, CER has nothing to do with discovering better treatments or achieving a better understanding of disease. CER is simply supposed to rank existing treatment methods.

The Institute of Medicine (IOM) has winnowed down some 1,300 topics suggested by “stakeholders.” Of the IOM’s 293 recommended primary and secondary research priorities, 50 (by far the largest number) pertain to “health care delivery systems”; 29, to racial and ethnic disparities; and 22, to functional limitations and disabilities (John K. Iglehart, N Engl J Med, posted 6/30/09).

Half the recommended primary research priorities for delivery systems concern how or where services are provided, rather than which services are provided.

An IOM committee also recommends “determining the most effective dissemination methods to ensure translation of CER results into best practices”—i.e. enforcement.

The goal of CER is indistinguishable from that of managed care: “delivering the right care to the right patient in the right place at the right time.”

Cancer is the focus of only six primary CER topics, of which one is related to congressional concern about increased use of advanced imaging.

The $1.1 billion is only a down payment. A new nonprofit corporation is expected to carry on, financed by a $1 annual “contribution” from each Medicare beneficiary and each privately covered life (ibid.).

CER, by proponents’ own admission, achieves nothing in itself. It merely “represents a significant investment in one of the translational steps toward improving the quality of health care for all” (Patrick H. Conway and Carolyn Clancy, N Engl J Med 2009; posted 6/30/09).

Operationally, CER means setting up a bureaucracy and dividing the funding among stakeholders. The content for the materials and methods section of a standard research report—consent, an institutional review board, control groups, validated data collection tools, defined endpoints, statistical procedures—appears to be absent.

There is no evidence that CER will decrease costs, improve quality—or produce any scientifically meaningful data. But for its proponents, there is no danger that the reformed system will be proved inferior, as there is no “usual care” arm to the protocol.

For example: determining patients’ needs—by talking to patients. Determining the comparative effectiveness of various treatments in individuals—by interviewing and examining patients. Determining the cost and value of differing options—by permitting prices to equilibrate in a direct-payment model.

Additional information:

12 thoughts on “Myth 5. Cost control and quality will emerge from comparative effectiveness research.

  1. How many studies showing improved outcomes have subsequently been disproven? Look at beta blockers in the peri-operative period, Aprotinin for cardiac surgery, newer v. older anti-depressants. There are too many jobs in present day healthcare providers, companies, etc to have a significant reform. It would mean a tremendous negative impact on employment and GDP not to say tax revenues.

  2. The treatment that is most efficacious for a particular patient may not be the treatment that is most efficacious for a population of patients studied as a whole. In part, this is based on the individual’s unique biology; the individual’s priorities, circumstances, and beliefs also contribute to therapeutic success or failure. It is important to have many options available in the therapeutic armamentarium. CER appears to be a major move toward treating both physicians and patients as interchangeable mechanical parts, rather than individuals with unique talents, insights, physiology, and needs.

  3. In order to practice medicine or engage in any productive activity an individual must be free to think and act on his own thinking. The human mind does not work under force. No man or group of men can force an idea into anothers mind. Force can intimidate, threaten, torture, imprison or cajole but the mind is paralyzed by force. Such actions by any man and especially government agents are immoral. They paralyze man’s only means of knowledge and his means of survival. A moral government protects men from the initiation of force by other men and nothing else. For the government to initiate force against those it is authorized to protect by the consent of the governned, is evil in action. Physicians must learn and understand the morality of freedom from government controls in order to protect themselves from this atrocity. The moral method requires that doctors care for their patients and charge for their services by mutually agreed arrangements free of all government regulations and interferrence.

  4. I read the linked paper and saw no mention of “success” in “trial studies” of the proposed comparative-effectiveness research (CER), “which has recently been referred to as “patient-centered outcomes research”. Per the authors, “[t]he purpose of CER is to provide information that helps clinicians and patients choose the options that best fit the individual patient’s needs and preferences.” What have been the results where this paper states CER is already conducted: “by the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), the Department of Veterans Affairs (VA), and others”? And what of those results for “provid[ing] information that helps clinicians and patients choose the options that best fit the individual patient’s needs and preferences” compared to a control group without CER? It seems to me that this is essential missing information before “investing” (at least) “$1.1 billion in CER funds” – otherwise known as money extorted from taxpayers – and enlarging an already enormous government bureaucracy between the doctor and patient. Myth 5 refers to such missing information in its conclusion.

    I saw no comments on this NEJM website page for the article – http://healthcarereform.nejm.org/?p=689 – although there is a form for such with the notice, “comment moderation is enabled and may delay your comment.” I hope that representatives of AAPS have made comments at NEJM’s website that include those here in Myth 5. Simply publishing these points at AAPS’s own site will miss many of those physicians and interested others who are undecided or still open to logical reasoning on this subject. If the submitted comments to NEJM by one or more AAPS representatives do *not* appear, that would be information to be shared here and elsewhere – widely and loudly!

  5. What is the alternative? To allow physicians to do whatever they want,even if there is evidence of a better way to manage a patient.
    Good Doctors should not be afraid of comparative effectiveness reseach.They should welcome it,it will allow you to demand a more expensive treatment for our patients if that is what works best.It will allow us to have a serious debate about how to best used our limited resources.On the other hand we should preserve the right to challenge
    the results,or if the patient and doctor agree to it,choose a diferent course but the patient or his private insurace should paid for it.

  6. Is it necessary to address the false claims that proponents are making about Cost-Effectiveness Research? It is illogical to argue point by point against nonsense. The goal of Obama, eta al is CONTROL & CONTRACTS, not quality.

    1. Create a “crisis.”
    2. Offer “the solution.”
    3. Create a bureaucracy, new taxes, fees and regulations.
    4. Funnel dollars to your supporters and entitlements to your voter block.

    REPEAT…

  7. Clearly “Dr Arrasque” is a government plant–no physician who actually treats patients thinks this way–Maybe just a new doc–you really believe serious debate will be entertained? Please!! Just another way for the Gov to tell us what to do–cookie cutter medicine that doesn’t apply to most of my pts. Aggree with other writers and “who is John Galt?” I think we need him now more than ever!!

  8. The relationship between pt. & Dr. is as unique and indivdualized as that between a married couple. Any effort or scheme to intrude upon that relationship, whether by gov’t or any other regulatory entity will inevitably detract from the effectiveness of medical management. For the best interest of patients, medical practice must be relieved of all involvement by third parties. Those intrusive third parties include insurers, hospitals, clinics, government and all other regulatory entities. The medical profession needs to issue a Declaration of Independence. Let the motto be: “Get off my back and let me do my job”.

  9. Ladies and Gentleman,I have news for you. The old way-when you did “things” just.. because…is ENDING.Dr Galt, we are not creating a crisis,”we have a crisis”. The huge variation in the way we the Doctors treat the same medical condition with no difference in outcomes,quality,patient satisfaction,cost,or whatever other measure you can think of, is not a secret anymore. The payors know it,more importantly,OBAMA knows it. The real challenge for Doctors is to have credible ways to demonstrate that what we do is valuable, otherwise the government,i nsurance companies, or hospitals in India etc..will tell us what to do.

  10. To Dr Arrascue—-Look at how Congress and Obama are MANDATING outcomes research into POLICY!! I have no problem if the TRUE HONEST MOTIVE is to provide me with a means to improve care. I however TAKE OFFENSE that my government that I pay MORE than my fair share of TAXES to (ie, “spread the wealth”) is going to force me to comply with what really is an UNPROVEN methodology—-and has the nerve to PENALIZE ME if I do not comply. If they offered a PAY FOR USE INCENTIVE to use HIT, I would be more likely to comply. I also have NO ASSURANCE from government that they will not use HIT as a RATIONING TOOL. ENgland and Canada base a lot of their coverage decisions on a patients age—–and I am not certain that I agree with that. We all know that there are plenty of UNINSURED in AMerica—-but Daschle and Obama are casting the blame on PHYSICIANS—-without having the GUTS to ACCEPT RESPONSIBILITY on the part of GOVERNMENT as well!! PAtients/Consumers are equally guilty as physicians in the “blank check” mentality regarding HEALTH CARE SPENDING—-you can’t blame either one because GOVERNMENT in it’s REGULATIONS AND RESTRICTIONS has not allowed either to possess :the true knowledge of what things cost. All I am saying is you have a tough sell with HIT on the plan that Tom Daschle and President Obama are RUSHING to get passed. ANd furthermore, if we are truly a nation of EQUALITY, then why is the HHS “PAnel of Experts” lacking representation from PRACTICING PRIVATE PHYSICIANS??

  11. CER will inevitably lead to hard rationing as costs escalate. As a young surgeon one would consult the textbooks and decide which treatment was appropriate for which patient; e.g. prophylactic antibiotics or DVT prophylaxis.
    OR personnel and doctors soon figured outthat sanctions are enforced for omissions, not commission. It became much easier to apply these to any and all comers rather risk the wrath of the Joint Commision or their local hospital enforcers.
    A recent published study by two local hospitals on nasal screening for MRSA found the major result was a dramatic increase in spending for antibiotics without comparable benefits.

  12. Pingback: Myth 26. Government-directed rationing will be rational. « AAPS News of the Day

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