In an interview with The New York Times Magazine, President Obama suggests that comparative effectiveness research — that is, research that compares clinical outcomes of alternative therapies used to manage the same condition — leaves doctors, patients, and the government with some difficult choices:
So when Peter Orszag and I talk about the importance of using comparative-effectiveness studies as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions. […]
Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting….So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here. […]
It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.
Obama highlights the anxiety surrounding comparative effectiveness research. We spend too much money on ineffective treatments, but designing a policy that lowers the use of unnecessary/unproven procedures and preserves access to experimental treatments or other unproven procedures is tricky; it’s a source of political concern and contention. Providing doctors with independent analysis about which drugs work and which don’t could save money and countless lives. But that’s the easy part. Almost everyone agrees that telling doctors that that drug X causes more harm than good would encourage providers to switch course and benefit the patient.
What’s more difficult is netting savings from unnecessary medical procedures and discouraging the system from over-treating patients. As the President points out, “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here” and it’s unclear that putting these patients through surgery during the last weeks or months of their lives is best for the patient. America’s medical culture and current payment structure dictates that you have to do everything in your power to extend a person’s life — by hours, days, or weeks — but the patient is rarely consulted. As Dr. Robert Martensen, author of “A Life Worth Living: A Doctor’s Reflections on Illness in a High-Tech Era” and the director of the museum and the office of history at the NIH, recently explained on NPR’s Fresh Air:
What’s different in American hospitals is that advanced technologies, aggressive interventions, keep getting applied to patients and literally applied right up until the body can no longer respond….Nobody stands back and says this patient is dying. Nobody says it to the family. Nobody says it to the patient if the patient is responsive. Things just keep getting done.
And the result is that, I think, we who are doing these treatments are causing great suffering. So there are structural problems in the system, and the result is that the patient who doesn’t want any more aggressive treatment, who just wants comfort care, can feel very frustrated.
This isn’t to say that the government should dictate a certain course of treatment. That should be left to the patient and her/his doctor (a conversation about different treatment options and choices can only improve patient satisfaction). But what the government can do is provide doctors with unbiased information about which treatments work and provide incentives for providers to focus on care quality and not care quantity (i.e. payment reform)
Today a doctor can spend hours talking to a patient like Obama’s grandmother about end-of-life decisions, discussing what matters to them, relevant medical history etc.. but in New York, Medicaid only pays $18 for that service. If however, a doctor is to recommend a complicated procedure, it would be well compensated.
A model that encourages providers to over-prescribe treatments of dubious quality and necessity is unsustainable and a cause of medical inflation. If we’re really serious about lowering health care costs, then the first step is comparative effectiveness research. But to really generate savings, “we will need legislation to provide incentives on penalties for following or not following where that information leads.” That isn’t health care rationing. It’s just smart medicine and good economic policy.
,A colleague points out that the 80 percent number — “the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill” — improperly combines the chronically ill and those near death. Also, the statistic that measures the treatment received at end of life is retroactive. That is, while the researcher can discern that the patient was in the last year of life, the patients and her/his doctor does not necessarily know that death is imminent. Keeping this in mind, prescribing aggressive treatments to extend a patient’s life (by 10, 20 years) is certainly reasonable.