The Problems of Comparative Effectiveness Research

Opinion Zone,Ben Domenech

On its face, comparative effectiveness research (CER) in health care doesn't sound like a bad idea.  If you're a politician or a taxpayer, you don't want to waste money.  CER’s appeal is fairly simple: we're going to waste less money by preventing doctors from doing things that aren't effective, and we're going to determine what is effective by studying it rigorously.

Yet there are problems that emerge for a number of reasons.  One significant problem concerns the details of the studies involved, and another concerns the context within which CER operates, which is ever-increasing government control of health care.

First, the practical reason: making CER happen is a lot harder than it might seem at first.  Forming conclusions which affect the lives of millions can't happen based on thin, outdated strands of data.

Last fall the Agency for Healthcare Research and Quality (AHRQ) within HHS published a report on the Comparative Effectiveness of Nonoperative and Operative Treatments for Rotator Cuff Tears. The key question is whether surgery worked best or not, but the dataset has more holes than Swiss cheese, a fact HHS acknowledged, based on the different patients and scenarios involved.   AHRQ found in part: “For the majority of interventions, only sparse data are available, precluding firm conclusions for any single approach or for the optimal overall management of this condition... Overall, the evidence shows that all interventions result in substantial improvements; however, few differences of clinical importance are evident when comparisons between interventions are available.”

Repairing torn rotator cuffs isn’t the only medical procedure where research is ambiguous.  Many doctors will tell you that this is the case in the overwhelming majority of cases they face - that facts about the medical history of a patient and countless other factors, some quantifiable and reducible to practice guidelines but many of them not, make CER impossible.  The extraordinary complexity of medical diagnosis and treatment explains why most published studies about the effectiveness of new drugs or therapy are later contradicted by new studies.

Now, the response from those who support CER is: we just need more data!  Well, how much data is enough data, and who decides what is enough data to result in a decision directing care for millions with the sweep of a pen?  Will it be an unelected bureaucrat, a board of unelected bureaucrat, or an appointee who was never confirmed by Congress, such as current head of the Centers for Medicare and Medicaid Services, CER fanboy Don Berwick?

This brings us to the principled reason why those who favor small government should oppose CER, which functions as a mandate to doctors: government shouldn't be in the business of deciding these questions.  Even if we had the data, the decision power should not rest in the hands of what is becoming a government monopoly on health insurance, which does not provide real freedom to doctors and patients to come to any alternate decisions for those who live on the edges of the bell curve.

Advocates of CER often say their goal is to find and encourage what is best for patients, and certainly CER can be used in this way.  But when the data gathered is used by government agencies to lower spending - such as by favoring older, cheaper drugs over newer, more expensive ones, as has been the case in Britain - the priority becomes the financial bottom line, not the best interests of the patient.

As health policy expert Avik Roy has pointed out, “The reason why new health care technologies are so expensive is because consumers aren’t involved in buying them.” If you examine the American economy, you’ll see new technologies aren't exploding costs in other areas of industry. Your cell phone and your computer are getting smaller, faster and cheaper, but in health care, consumers are already several times removed from the price and value of the technology involved in their health care - the insurer pays for the product or service, while the employer or the taxpayer typically pays for the insurance.

Fundamentally, creating a bureaucracy of unelected Washington elites who pick winners and losers in health care is not the proper role of government.  The consumer’s role in the marketplace is already artificially restricted by government policy, and under a system where CER is fully deployed, your doctor's role - the ability to help you make informed decisions about your care - will be further diminished.

Despite what President Obama said during the health care debate about doctors taking out your tonsils needlessly for the monetary benefit, the fact is that most doctors want to treat patients and treat them well, solving their problems and alleviating their pain.  A fully deployed CER gives government the power to tilt the playing field in favor of whatever's cheaper, which can and I believe will mean overruling doctors to the detriment of patients.

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