White Coat Underground

The New York Times is reporting that the economic stimulus bill will include over a billion dollars to fund research into medical evidence. This is a good thing, but it’s bound to be controversial. I’ve mentioned before that we need to spend money to improve our medical infrastructure, and this could be a step in the right direction.

Much of what we do in medicine is science-based, and much of it has evidence to support it, but some does not. There are plenty of open questions about how we practice medicine, and in order to deliver safe, quality care, we need answers. For example, a recent study in the New England Journal of Medicine compared surgical and non-surgical therapy for arthritis of the knee. Surgery made logical, scientific sense, but it had never been carefully compared to non-surgical therapy. The study showed that conservative therapy, which is cheaper and less invasive, was just as effective as surgery. This doesn’t mean that surgery will never help, but it is strong evidence that we should treat arthritis of the knee more conservatively. Studies like this aren’t free, but if their results are reliable and repeatable, they may save us a lot of money and possible surgical complications.

So the idea of investing more money into comparing medical treatments makes sense, both scientifically and economically. Now there’s a lot of predictable schreing about this, and since my L5 nerve root is still an issue, it’s making me extra cranky.

As Congress translated the idea into legislation, it became a lightning rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive treatments and, thus, to ration care.

In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person’s health care by enforcing clinical guidelines and treatment protocols.

I’m not sure that the legislation says anything about enforcing clinical guidelines, but to be fair, there is some implication along those lines.

And so what? Right now, my patients’ insurance programs do exactly the same thing—if I prescribe an angiotensin receptor blocker for blood pressure control, I’m going to be asked to justify why I am giving this rather than the cheaper and as-effective ACE-inhibitor. The answer is usually that the ACE-I caused side-effects, but the question isn’t stupid. Why should an insurer pay more when an equally effective, cheaper alternative is available?

If we have more evidence to work with, we can continue to make even better decisions regarding care. It may seem intrusive, but it’s not very different from what we do already. And honestly, I’d like to know if I’m more likely to get relief of my radiculopathy from surgery or conservative therapy. I will not be offended in the least if my surgeon got a call from my insurer asking if surgery was really my best option, as long as the answer was supported by good evidence.

It rings rather hollow when people protest against gaining more knowledge. Libertarian types complain that this will inevitably lead to government interference (and it might, and maybe it should) but to ignore the need for evidence is absurd. We, as physicians and patients, need more knowledge, not less, and we shouldn’t be afraid of where the data lead. It’s a no-brainer. But then, some people are a little short on brains.


  1. #1 Mike
    February 16, 2009

    I hope that you are being disingenuous when you say there is no difference between an insurance company denying coverage for treatment A over treatment b and a government making it illegal to provide treatment A over treatment B. The former is a voluntary association between an individual and a private party. The latter is an involuntary association with the threat of force or jail for those who break the law.

  2. #2 PalMD
    February 16, 2009

    I think you read into this more than was there, but I’ll bite.

    Remember, there is no talk of making anything illegal. That’s just bullshit.

    “Volutary” associations with insurance companies are illusory. You need insurance, you take whatever you can get. That, and the largest insurer in the US is…Medicare, a gov’t agency.

    I think you’re gently strolling over to a big straw man.

  3. #3 iRobot
    February 16, 2009

    most people get their insurance from work. They dont choose what insurance they have. If they are lucky they might have 2 plans but it is certainly not an instance of free choice and shopping around.

  4. #4 Marilyn Mann
    February 16, 2009

    My co-blogger Merrill Goozner did a post on this. Sounds like you are basically on the same page.


  5. #5 David
    February 17, 2009

    NIH has funded comparable effectiveness studies for years, in numerous fields. One example is NASCET, a randomized trial of surgical versus medical management for stroke prevention when carotid stenosis is present. NHLBI funded ALLHAT. So what’s really new here? The new piece is the idea that this may be the first step towards constructing something like the UK’s NICE. Conservatives have somehow hallucinated a link from “government funding comparativeness research” to “government regulating healthcare.”

    NICE doesn’t actually fund clinical studies. It just evaluates available data. A proposal to gain more health care data on controversial topics seems to be very different than a proposal to create a NICE-like empire.

    On the other hand, NCCAM supposedly funds studies of alternative medicine, and their findings haven’t resulted in the elimination of sham practices.

  6. #6 PalMD
    February 17, 2009

    I should perhaps make it more clear that I am much in favor of the idea of funding effectiveness studies. I’m also in favor of making clinical, evidence-based guidelines easily available.

    I’m not all that keen on gov’t control of the physician-patient relationship. That being said, there’s a lot of bad doctors out there who practice crappy medicine without regard to evidence? How do we fix that? I don’t know.

  7. #7 kirsti
    February 17, 2009

    I think part of this argument beyond insurance is also about the costs of new drugs, new devices and physician involvement in these enterprises which has led to incredibly complicated negotiations and uses of pharma and devices which do not have evidence of their effectiveness, are incredibly expensive and therefore jack up the rates of healthcare and insurance. Not to mention the legal liabilities for everyone concerned. So in some ways, I think the questions of evidence and effectiveness need to be asked and should be funded, because hopefully we might begin to tackle the waste and expense of a non-performing system of healthcare.

  8. #8 Donna B.
    February 18, 2009

    I don’t think I’ve been against gaining knowledge and evidence or figuring out what works best overall. I am suspicious of large databases (that I know from experience contain errors) and feel a need to know who is using them for what.

    For the obligatory anecdotal evidence: my son is insured by Medicare (stemming from a childhood disability) and has just been denied any coverage of a drug that he’s been using for 3 months (samples from his doc) with very good results – it treats what he’s taking it for without interfering with other drugs or worsening other health problems.

    However, his denial states that he must FAIL for 90 days on an alternative treatment before he’s approved for this drug. He has failed on this exact alternative treatment but it was more than 3 months ago, so it doesn’t count. He must fail again. Failure means hospitalization, which is much more expensive than the drug.

    How does this make medical or money sense?

    I haven’t read the final version of the stimulus bill (has anyone?) but I read substantial portions of several of the preliminary versions and provisions appeared and disappeared like monsters on the sides of the highway in kudzu covered Mississippi late at night when sleep-deprived.

    (hey, I think that last paragraph could be a Bulwer-Lytton entry.)

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