How Much Can Comparative Effectiveness Research Do?
Neither side in the debate over comparativeness effectiveness research is being entirely honest. The pharmaceutical companies and device makers say they fear that patients won't receive the care they need if payers use this research to justify not covering a drug, device, test, or procedure. But of course, they--and the doctors and hospitals who use or prescribe their products--stand to lose a lot of income if Medicare and private insurers decline to cover some interventions.
On the other side, the proponents of comparative effectiveness research--which the Institute of Medicine is set to launch with $1.1 billion in government funding--maintain that we need to find out what works best so that patients will receive the best treatments. That's a strong argument; but, as the Obama Administration and Democratic Congressional reformers undoubtedly know, objective research could justify not covering interventions of marginal or lesser value--and that could save a lot of money.
Just how much could be saved is suggested by a recent Chicago Tribune article in which leading experts were asked which areas of medicine need comparative effectiveness research the most. The experts listed obesity, lower back pain, autism spectrum disorders, chronic stable angina, prostate cancer, chronic pain, depression, early-stage breast cancer, and joint replacements. Collectively, these conditions account for a huge portion of health costs.
But can comparative effectiveness research really achieve its supporters' goals? One indication that it might yield to political considerations is provided by the current battle over virtual colonoscopies. In February, CMS tentatively decided to end Medicare coverage for virtual colonoscopies on the ground that they are less effective than traditional colonoscopies for detecting cancerous polyps in the colon. Some observers also pointed out that if such a polyp were found, a patient would still have to undergo an optical colonoscopy.
In mid-April, however, CMS revealed that it was still considering whether to cover virtual colonoscopies, which are done with CT scans. (A decision is expected in May.) The scientific evidence hadn't changed. But the American Cancer Society, which endorsed virtual colonoscopies last year, said that Medicare patients deserved to have this option even if the evidence for its efficacy is weak. Meanwhile, interest groups--including medical imaging companies and healthcare providers--began lobbying Congress. As a result, 50 members of Congress wrote letters to CMS--and the virtual colonoscopy decision was put on hold.
Of course, it can be and has been argued that if virtual colonoscopy were widely available, more people would be screened, and more cancer would be found while it was still curable. Only half of people over 50 now get colonoscopies, partly because it's a very unpleasant procedure.
On the other hand, history has shown that when a procedure becomes easier to endure and less risky, its use soars. A good example is laparoscopic procedures, starting with the one that replaced open surgery for gallstones in the '80s. That was a useful advance that eliminated the pain of many people without subjecting them to a more invasive procedure. But its introduction caused a spike in gall-bladder operations that more than offset the lower cost of the laparoscopic variety.
Moreover, medical "advances" of lesser value will continue to be advocated by those who profit from them. When, as a result of comparative effectiveness research, payers have to decide whether to cover a particular type of back operation that has not helped patients any more than conservative therapy, they will undoubtedly find themselves locked in a political fight with surgeons who stand to lose income if nobody can afford the procedure. So we should not expect too much from comparative effectiveness research, as it's now conceived.