It all sounds very reasonable: to set priorities, to use the most effective therapies, to serve the neediest first. Rationing is a given, say reform advocates. Insurance companies already do it. Let’s just make it rational and fair.
Some say that Comparative Effectiveness Research (CER) isn’t really about rationing. “Nothing in the legislation…provided for payment restriction based on CER findings,” writes Jerry Avorn (N Engl J Med 2009;360:1927-1929). It’s “Orwellian” to suggest such a thing. Anyway, “unaffordability rations care far more than comparative studies ever could.”
The end-stage of rationing actually has little to do with comparative effectiveness. There are more basic questions: “Have you suffered enough yet?” And “Can you get through the clinic door?”
One young Canadian mother suffered from pain and incontinence and required a walker, because of spondylolisthesis. She aggressively presented herself at four surgeons’ offices before or after hours or at lunch, pleading her case. Four surgeons saw her. Three said she was she’d just have to wait, as others were either older than she was and/or had already suffered longer. Finally a surgeon took pity on her and worked her in—only 6 months later—because she was “too young to have to live like that.” Never mind the need for emergent surgery in the event of neurologic compromise, or more than 2 years of total disability.
CER results can’t be applied until a patient can get a diagnosis. A video team documented efforts to get help from Canadian clinics, and then interviewed a number of Canadians.
CER is not needed to determine that it is traumatic and less safe to give birth in corridors or reception areas because labor beds are full—as 4,000 mothers did in the UK in 2008. The government cut maternity beds by 22%, although birth rates were up 20% in some areas, and spending on the National Health Service was tripled (Daily Mail 8/26/09).
A pediatric ophthalmologist, in the only such practice in Georgia still accepting Medicaid, writes that Medicaid will not pay for the antibiotic needed for an infected corneal ulcer. It takes a year to approve a contact lens after surgery for neonatal cataract. Private funding fills the gap. No research is needed to tell the difference between successful treatment and likely blindness (Zane F. Pollard, M.D., American Thinker. August 2008).But how many such treatments would be denied while approval wended its way through a system with 111 bureaucracies?
With or without CER, government plans always ration care. “The idea of an omnipotent board that makes unpopular decisions on access and price isn’t a new construct. It’s a European import. In countries such as France and Germany, layers of bureaucracy like health boards have been specifically engineered to delay the adoption of new medical products and services, thus lowering spending” (Scott Gottlieb, Wall St J 6/25/09).
We have our own examples in the U.S., as in Oregon.
Throwing $1.1 billion into CER is guaranteed to produce no new knowledge—only poorly controlled data about the implementation in different practice settings of methods already tested for safety and efficacy in well-controlled studies (Naik AD, Petersen LA. The neglected purpose of comparative-effectiveness research. N Engl J Med 2009;360:1229-1231). It will provide the rationale for rationing.