'Comparative Effectiveness' In Health Care Debated

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Congress must consider costs as it moves forward with health care bills. Comparative effectiveness, which involves comparing the difference between different treatments, is one tool. iStockphoto.com hide caption

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Stethoscope on calculator

Congress must consider costs as it moves forward with health care bills. Comparative effectiveness, which involves comparing the difference between different treatments, is one tool.

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Earlier this year, President Obama and Congress decided to spend more than a billion health care dollars for something known as "comparative effectiveness" research. The research involves side-by-side studies to determine which medical treatments work best. The findings help policymakers decide which treatments are most effective for each health care dollar spent.

Yet as Congress struggles to craft a health care overhaul plan that will cut costs, lawmakers on both sides of the aisle are balking at using comparative effectiveness to limit coverage or reimbursements.

Senate Republican Leader Mitch McConnell says he has no problem with the research. But he does have a problem with using its findings to restrict health care options.

"Americans want their doctors to have clinical information on which treatments work best and which ones don't," McConnell said. "But government bureaucrats shouldn't be able to use that information to determine what treatments Americans can or cannot get. That's a decision we currently leave between a patient and his or her doctor. And that's where it should remain."

There is no American government entity dedicated to deciding which treatments patients can get. But there is one in the United Kingdom: the National Institute for Health and Clinical Excellence, or NICE. As the Senate health committee recently crafted its version of a health care overhaul, New Hampshire Republican Judd Gregg railed against what NICE does:

"In the most crass terms, what they do in England is they say that a life is worth 20 to 40,000 pounds a year, and then if the procedure exceeds that price, you don't get the procedure," Gregg said. "I don't think we want to go on that way, down that road in this country, so I think we have to have an absolute ban on that concept of rationing."

Maryland Democrat Barbara Mikulski assured Gregg that comparative effectiveness research wouldn't be used in the United States to limit health care options.

"We're not doing it the U.K. way," she said. "We're doing it the USA way. And the USA way says it shall not be construed for payment, coverage or treatment."

Sen. Christopher Dodd of Connecticut said the insurance industry already rations health care by limiting payments and denying coverage to people with pre-existing health conditions. Dodd said there is a need for comparative effectiveness research, but quickly added, "I don't know of anyone that believes for a single second that we ought to be rationing care to the point where we deny benefits to someone."

Lessons From Medicare

Sean Tunis sees it differently. He was chief medical officer at the Centers for Medicare and Medicaid during the recent Bush administration. He says that reducing health care spending "presumably means you're spending less than someone might otherwise want."

"That's rationing," he says.

Tunis says comparative effectiveness research can be a useful tool, but the problem has always been how to use its findings without igniting a political firestorm.

"You know, that's a process that, in this country at least, we've never figured out ... a good, robust politically viable way to do that," Tunis said. "That's the kind of process I used to run at the Medicare program, and ... it's the third rail of health care. ... It's the process that is really always viewed as getting in between a doctor and a patient."

The health care bill that two House committees approved last week has a 24-page section on the funding and use of comparative effectiveness research. It creates both a center to do such research and a commission to oversee it. But the bill then adds this caveat: "Nothing in this section shall be construed to permit the Commission or Center to mandate coverage, reimbursement, or other policies for any public or private payer." In other words, Congress is taking a pass on ordering that the research findings be used to cut costs.

New Jersey Democrat Rob Andrews, who chairs the House subcommittee on health, says Congress is doing the right thing.

"We think that the private insurance marketplace for competitive reasons will adopt a lot of these changes, and that's why a mandate isn't necessary," he said.

But Tunis doubts anyone will heed the federally funded research if doing so remains optional.

"There's plenty of opportunity for profit in health care without conducting your business efficiently," he says, "so I'm not sure that just ... left to the current marketplace mechanisms, you know, that there ... would be much natural incentive to use the comparative effectiveness research information."

That could all change, Tunis says, if Congress would add incentives for the kind of health care efficiency that relies on comparative effectiveness research.

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