A Robust Comparative Effectiveness Research Enterprise

I post this link to the Health Affairs blog today, in part to keep it handy... for myself.  It is a must-read for health policy, health services, clinical and biomedical researchers.

http://bit.ly/b1ZvcA

Kudos to Darren Zinner, a former classmate, for his work on this!

On Comparative Effectiveness Research, Why Do So Many Bloggers Get the Facts Wrong?

Here is an example of poor quality blogging on the topic of comparative effectiveness research in medicine. Dozens and perhaps hundreds of blogs have addressed this topic in the past several months, and many of them keep repeating the same simple errors.

The blog I point you to at the top of this post, for instance, misses key facts about CER, including the definition of CER. According to the Congressional Budget Office (scroll to page 3), CER is "a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients." Other definitions taken from the  recently passed legislation (see page 1620, "PURPOSE"), the Institute of Medicine (scroll to bottom of page 1) and the now terminated Federal Coordinating Council on Comparative Effectiveness Research all point to this same idea - that CER is designed improve information about which treatments work best for which patients and under what circumstances.

Comparative effectivenes research is therefore meant to replace current practice in which summary results from clinical trials are applied to every patient, with a better practice in which patient-specific evidence from clinical research and real-world practice settings is applied to patients on a case-by-case basis.

It is clearly spelled out in every Federal document that describes the role of CER: this research is designed to make comparisons between treatments and apply the results to individuals, not to whole populations.

A second major gaffe in this blog suggests that the information will be used by some invisible hand (read: government) that stops the use of certain medical interventions. This blogger writes: "Comparative effectiveness research is the process of comparing the costs and the results of various treatments to decide whether the more expensive treatments actually yield better results. And of course if the answer is no, the more expensive treatments stop being used (for the most part)."

I'm not sure what "(for the most part)" is supposed to mean. This claim is false. It can be contrasted with the newly passed law, which actually states:

"The [CER] Institute shall ensure that the research findings ...  not be construed as mandates for practice guidelines, coverage recommendations, payment, or policy recommendations" (pages 1634-35)

and further on:

"COVERAGE.—Nothing in this section shall be construed to permit the Institute to mandate coverage, reimbursement, or other policies for any public or private payer" (pages 1647-48)

and still further on:

"The Secretary shall not use evidence or findings from comparative clinical effectiveness research conducted under section 1181 in determining coverage, reimbursement, or incentive programs under title XVIII in a manner that treats extending the life of an elderly, disabled, or terminally ill individual as of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.” (pages 1652-53)‏

So, why do so many bloggers get the facts wrong on CER?  I'm pretty sure they are taking shortcuts. I'm sure it is easier to work from political talking points than to obtain verifiable source material and report on it. In the case of comparative effectiveness research, the source material is available and verifiable, but it is buried under a mountain of low quality blogging.

The President's Speech

I snatched this from Nick Kristoff's twitter feed earlier today.

Harbinger Geese

My brother, David Concannon, went to the extra effort to clip, scan, save and send an Op-Ed by James Carroll from the Boston Globe this morning. I thought to myself, "If he went to the trouble of digitizing print media in the era of hyperlinks and e-mail, it must be really good."

It is good.

Thanks Dave!  Here's an image of the real life print version. 

Coming Between You and Your Doctor

Another well written piece in today's blogosphere:  Coming Between You and Your Doctor

Why Comparative Effectiveness Research is Needed

Should health insurers be held accountable for skyrocketing premiums?

Congress and the President are beating up on health insurers for raising premiums at rates that are literally killing people. The rate increases are so high that many people who desperately need health care will no longer be able to afford their premiums. Anthem Blue Cross, for instance, raised rates for non group coverage as much as 39% this year: www.bit.ly/9uNKw6.

While increases of 39% are no doubt extreme, health insurers are not the sole villains in this story. Behind these increases are sharp increases in the sale and use of unnecessary high tech medical care. Medical device and pharmaceutical manufacturers, hospitals and specialist physicians have been overselling questionable medical technology to US consumers for decades. They have been dipping into our wallets without our permission and it is time we figured out how to make them stop. In today's Washington Post health blog (www.bit.ly/98BfPK), Ezra Klein points out correctly that insurers tried to say no to some of these practices in the 1990s, and they got killed in the courts over it.

Health insurance premiums are by definition equal to health spending plus health insurance overhead. While overhead might be too high, the real reason that premiums are going up is that spending is going up.

Medical care seems to get less value from technology than other industries do. One reason for this is that physicians and hospitals regularly oversell unnecessary high tech procedures at an astounding rate. For example, a recent study in the Journal of the American College of Radiology www.bit.ly/a6zmev showed that 1/4 of all radiology referrals in a large medical system were unnecessary. In the US healthcare market, there are no players around to stop referrals of this kind from being carried out. All of the incentives for hospitals, specialists, medical device manufacturers, pharmaceutical companies - and yes, health insurers - are aligned keep healthcare consumers on an ever-rolling treadmill toward higher spending.

In the US, we have few solutions to this growing problem. This problem is going to continue unless we find the right way to say no to unnecessary medical care. We must find a way to stop the sellers of unnecessary medical technology from killing our wallets and our budgets. Until we do, health insurance premiums will continue to grow at rates that are literally killing people.

Map of Every Fast Food Burger in the US

This interesting map of US fast food burger joints was put together by the folks over at http://www.weathersealed.com/.  Great work!

Fast food burgers may be delicious once in a while. But what if you lived in a neighborhood that had no other inexpensive food sources?  I'd like to see map of farmer's markets and grocery store chains laid on top of this, to see where fast food restaurants dominate low cost fresh food stores.

http://www.weathersealed.com/2010/02/23/a-disturbance-in-the-force/

The Power of Better Information

In a provocatively written piece "Technology and the power to say no is real health reform" http://bit.ly/9JOZ7v, Dana Blankenhorn writes that real health reform involves saying no to the sellers of useless medical care and no to patients who refuse to make behavioral changes that would improve their health. By saying no, he means that we must stop paying for health care that doesn't work and for health care for people who don't deserve it.  I agree with his first claim and disagree with his second.

What's great about the article is the very strong case he makes for curbing the growth of healthcare costs by attacking it at the source. The growth in health care costs does not originate with the usual suspects - poor prevention, big government or with overpriced health insurance. Our problem originates with the sellers of health care - especially specialist physicians, high tech hospitals, medical device manufacturers and pharmaceutical companies. The sellers of high cost health care have been dipping into our wallets without our permission for many decades, and it is time we figured out how to make them stop.

It's the sellers of high tech health care who are causing the big hikes in health insurance premiums. It's not that we don't need some of the technologies they sell. It's that we have very little information about what we need and what we don't, and they aren't telling. They're too busy selling. 

So we need more information - comparative information - that tells us which interventions work well and which interventions are just dressing on the cake.  The Federal effort to fund better comparative effectiveness research is exactly what is needed. Once we have that information, we need to use it. We need to find the power to say no to some of these useless technologies and interventions. We need to aquire the the power to say no to the sellers of useless health care. We need to eliminate insurance reimbursements for health care that doesn't work. That's what we'll need if we want to see an end to 39% hikes in health premiums http://bit.ly/9uNKw6.

A recent article in the Journal of the American College of Radiology shows that in one large health care system in Washington State, approximately 1/4 or 26% of all referrals for diagnostic imaging services were not necessary. See a story on this study here:  http://bit.ly/a6zmev.  Many of these diagnostic procedures - x-rays, MRIs and CT scans - are very expensive, and we're paying for these procedures in our health insurance premiums. Why are we doing that and why don't we stop? Someone's got to start saying no. Dana's right about that.

That said, I don't agree with Dana that we must also learn how to deny care to overeaters, smokers and drinkers. The worst of our national health behaviors are undoubtedly killing our bodies and our wallets. However, the most effective strategies for defeating these behaviors and their outcomes - obesity among the worst of them - are not known.

We do know that obesity runs in geographic clusters.  In some regions of the country, people are overweight because there is no fresh food to be found, for miles. In these "food deserts," residents dine on fast and convenience foods. Obesity rates have skyrocketed in these areas over the last several decades. Effective strategies are needed to eliminate the deserts, not to penalize the people. To date, however, very little research has been conducted on what can be done and what might work to reduce desert-induced obesity.

Obesity also runs in social networks, and this finding has only been available since the publication of Nichoolas Christakis' groundbreaking article on that subject in the New England Journal of Medicine three years ago:  http://bit.ly/bHUmBL.  More information is needed to understand how social networks can be used to improve diet and exercise.

Interrupting the geographic and social determinants of obesity may be better than penalizing the elderly person who acquires diabetes after a lifetime of cheeseburgers.

But we need better information about what works and what doesn't. That's power.

The CEA Registry Blog: ‘Best practices’ to trim medical costs

The CEA Registry Blog: ‘Best practices’ to trim medical costs

Americans Still Want Health Reform

From a Kaiser Family Foundation poll, released today at: http://www.kff.org/kaiserpolls/8051.cfm

Question: For each element of health care reform I name, please tell me how important it is that this be passed into law. First, how important is (item)? Is that extremely important, very important, somewhat important, not too important, or should it not be done at all?

1. Reforming the way health insurance works. Proportion saying extremely or very important: 76%
2. Providing tax credits to small businesses. Proportion saying extremely or very important: 72%
3. Creating a health insurance exchange or marketplace. Proportion saying extremely or very important: 71%
4. Helping close the Medicare "donut hole". Proportion saying extremely or very important: 71%
5. Expanding high-risk insurance pools. Proportion saying extremely or very important: 70%

And here's an interesting chart:

And another:
 

Nurse Practitioners Push for an Expanded Role in Primary Care

Check out this interesting article about the push by nurses for an expanded role in primary care: http://www.bit.ly/dg7TSL. And check out this review of studies that compares advanced nursing care with physician-directed primary care: http://www.bit.ly/choFHP.

The nutshell? Advanced nursing care is often as good or better than care from a physician. And it costs less.

Although lower cost care is often equally as good or even better for the patient, there are few incentives in place to choose lower cost and lower intensity alternatives. People who are very sick may prefer to modify or even limit the intensity of the health care they receive. But everything in our system - and nearly everyone - points patients toward higher intensity.

This isn't exactly any one's fault. The whole system has us on a treadmill toward higher spending and higher-intensity care. Many insurers and health providers find themselves struggling to keep revenues high, which means the default choice is a physician over a nurse practitioner, a hospital over a community health center and a hi-tech over a low-tech intervention.

Just a little food for thought.

Health Care Stocks Rise on Death of Health Reform

In "Markets Salivate at Prospect of Healthcare Reform's Defeat," Ken Terry hits the nail on the head: http://industry.bnet.com/healthcare/10001627/markets-salivate-at-prospect-of-healthcare-reforms-defeat/ . He reports that "investors are pumping up healthcare stocks in the hope that reform will fail and that the free market will continue to push up health costs- and profits for the health industry." The Wall Street Journal reports separately that Pfizer and Merck stocks rose on investor "hopes for more concessions to be made in health legislation."http://online.wsj.com/article/SB10001424052748704561004575013480490353788.html?mod=googlenews_wsj

Where will these higher health costs and profits come from? Expect health insurance premiums to go up. Expect little help from the government or from the proposed center for comparative effectiveness research. The proposed center, whose intent was to compare alternative treatment regimens and suggest incentives for those that work best, will die with health reform.

I don't think this is what voters in Massachusetts had in mind yesterday. They wanted compromise on health reform, not open season on their wallets. Pharmaceutical and medical device manufacturers, hospitals, some insurers, and many medical specialists can celebrate. Their stocks are on the rise and healthcare markets remain almost entirely in their hands.

Does Brown's Election Signal a Compromise or an End to Health Reform?

I've heard it suggested that Scott Brown's election last night to the US Senate may bring about a new compromise on health reform. There is speculation in the NYT http://bit.ly/8jFTPd about a compromise that could bring Olympia Snowe back into the fold, or perhaps some effort that could bring both Snowe and Brown over to the reform camp. Presumably, Brown has to tack to the left to be elected again in Massachusetts, in less than two years.

But I don't see a compromise happening any time soon. Currently, no Republicans support the reform bills before Congress, and there is little evidence to suggest that the GOP will suddenly get religion.

Brown has suggested that states should be left to do health reform as they see fit. Snowe wants limited and perhaps no additional Federal involvement in the health system after reform. Neither of these positions can bring about reform of our system. Health reform in the US has to be predicated on one major change: everyone has to participate in the health system, at least at a minimum level. Without this change, "reform" isn't reform at all. Call me a pessimist, but I don't see this happening without increased Federal involvement.

If health reform fails to reach nearly every US resident in every market, the private suppliers of high cost health care interventions will continue to carve up markets, charge whatever they want, invent new "interventions" that have little chance of improving health, and over-treat unwitting patients with aggressive and unnecessary care. The "suppliers" I am referring to include (but are not limited to) pharmaceutical and medical device manufacturers, hospital systems and many medical specialists. It doesn't hurt that many patients want unlimited access to new medical technologies, whether they can improve health or not. All of the incentives are pointed in the same direction: toward newer and more expensive health care.

The suppliers of health care thrive on high cost and high tech interventions, interventions that are oversold to the American public. While some patients need new and expensive technologies, not all of us do. We are suffering from a technology binge in every corner of the US health system. Americans spend 16 cents of every dollar on health care, and the suppliers of high cost care won't mind if we spend 20 cents or more in a few short years.

As if on cue, Pfizer and Merck stocks rose on news that Brown had won the election http://bit.ly/6J07tO . Investors went to Pharma "on hopes for more concessions to be made to health care legislation." Concessions to Pharma? Is this what voters meant when they said they wanted more compromise?

I just don't see Brown or Snowe coming over to a health reform package that has any teeth. If a bill survives, it won't be strong enough to achieve anything meaningful. We should expect premiums for a healthy adult to rise well past $1,000 per month in a few years. That's what it will take to fund our voracious appetites for high cost health care.

Health Care Renewal: What the November, 2009, Breast Cancer Screening Argument Obscured

Health Care Renewal: What the November, 2009, Breast Cancer Screening Argument Obscured