Universal coverage, comparative effectiveness, and the muddying of the healthcare debate


A key component of health-care reform -- and saving our ass from going bankrupt and sick from spending too much on lousy treatments -- is establishing comparative effectiveness measures, otherwise known as "actually knowing WTF works and what doesn't."

This idea terrifies companies who don't want such objective measures. It also generates a lot of fear, partly via confusing or intentionally frightening arguments. Yet making sure we don't pay for stuff that doesn't work is key to reform -- a point made in this Times op-ed from libertarian economist Tyler Cohen, keeper of the blog Marginal Revolution.

Cohen argues that the main problem is, as he puts it,

the financial incentives for doctors and medical institutions to recommend more procedures, whether or not they are effective.

These were discussed vividly in Atul Gawande's recent New Yorker piece, and they are clearly a part of the problem. I think Cohen lets industry off a bit too easily when he says that drug-company profits aren't really part of the problem, for expenditures on drugs that either do little good or do little better than far less expensive drugs are costing us many billions as well; over the last two decades, for instance, we've spent scads of money on modern antipsychotics that cost 20 times as much as the drugs they replaced -- and only recently gathered enough data to show they work no better than the old ones.

Yet it's clear that the wild variations in how much doctors treat (and prescribe) are a major part of the problem. Are we willing to refuse to pay for the treatments that bring no benefit? This is Cohen's larger question here -- and he's not optimistic about the answer.

If we are willing to take comparative-effectiveness studies seriously, we could make significant cuts in Medicare costs right now. We could cut some reimbursement rates, limit coverage for some of the more speculative treatments, like some forms of knee and back surgery, and place more limits on end-of-life-care.

Those cuts alone will not solve the fiscal problem, but if we aren't willing to take even limited steps to conserve resources, we shouldn't be spending any more money elsewhere.

Of course, we have not made such Medicare spending cuts yet, and there are few signs that we will. A Kaiser Family Foundation poll found that 67 percent of Americans believe that they do not receive enough treatment and that only 16 percent believe that they have received unnecessary care. If the Obama administration covers more people with government-supplied or government-subsidized insurance, the political support will broaden for generous benefits, their continuation and, indeed, expansion of current expenditures.

This is a tricky damned business. As someone being just murdered financially by health-care costs (precisely because I can "afford" to buy health insurance -- $10K a year for $5k deductible plan; my healthy little family spent over $18 altogether last year and westill owe money, even though no one was even admitted to a hospital), I feel strongly that health-care reform should include a public plan, and generous premium subsidies, that provides full coverage at reasonable, income-based cost.

Yet the opponents of reform are making great gains in using the public plan to confuse, darken, distort, and generally muck up the discussion over health-care reform -- while vigorously fighting comparative-effectiveness measures in the background. They're doing quite well in rolling the press; as I noted yesterday, I was dismayed to hear Steve Inskeep of NPR grill HHS secretary Kathleen Sibelius, with a persistence never seen in, say, NPR's coverage of the run-up to the Iraq War, over whether the public plan was a "Trojan Horse" for (god forbid) a single-player plan or universal coverage; he even asked her if she was willing to put a cap on how many people such a plan would be allowed to cover, should it prove more attractive than the appalling options we now face. I can only hope we will soon hear him grill with similar vigor someone like Mitt Romney, and ask them, say, just how many people they think we should systematically leave uninsured, or explain exactly how the downsides of a cheaper, subsidized public plan would be worse than the downsides of the disastrous system we have now.

There are parties in this debate who are trying to define the "solution" as one that gives everyone the same level of "care" the most overtreated people now get -- without costing the country an extra dime. That's a formula for making nothing happen, of course -- which is precisely the real goal.

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I don't see why having insurance coverage only for treatments that have proven efficacy needs to be a problem for people. Even now many insurance companies require pre-approval for certain procedures.

We have to remember that diagnosis and treatment is not as simple as a flowchart though. Dr.s have the training to look at the patient as a whole and integrate a wide range of important information into diagnosis and treatment. A system that is too rigid would be a problem.

On a separate note... I'm concerned about how the Dr.s will make out as health care reform occurs. My wife and I are both for universal healthcare and she is a family practice Dr. I know that it might not be easy to have sympathy for docs in terms of money but it really is an issue.

We are in debt hugely from her education. She's finishing her residency now and hoping that her incredibly high monetary and time commitment will be financially rewarding. She works 80 hr. weeks, is incredibly smart, and delayed making money to get through school.

The US has a doctor shortage (especially family doc) and any cut in pay will only make the problem worse. Family docs in particular are paid lower than other specialties and that is why many people choose residencies in other specialties. If part of the health care fix is to have a family doc for everyone... this needs to change.

I wrote a slightly less well reasoned and grounded argument here:
I really don't understand why people here are so scared of a public option. Even when they can keep their crappy old insurance. If it's anything like Australia's system, sign me up.

Republiscumcan Senators Kyl Roberts & McConnell introduced a really bad idea as part of a public plan. They want patients to choose whatever they want as treatments instead of using comparative studies to find the most cost effective. Not that their plan is going to succeed, but...

By natural cynic (not verified) on 18 Jun 2009 #permalink

Comparative assessments are important, but it is equally important to understand the assessments and the questions being asked, otherwise those comparative assessments are worthless.

One example is your description (often repeated, but quite mistaken) about the antipsychotic studies. Modern antipsychotic medication is more expensive than older antipsychotic medications, and you are correct to note that studies have shown that their overall efficacy is similar, which you note.

However, you fail to mention that these newer medications were developed and are used not because of greater efficacy, but because the older medications had much higher risks of very serious (and potentially permanent) neurological side effects such as Tardive Dyskinesia.

Similarly, I suspect that the author is making similar mistakes with other procedures and treatments, He mentions "end of life care" without mentioning that one reason why some end of life care may appear ineffective is because much of it is palliative. It certainly may be the case that some treatments that are aimed at prolonging life may be futile or unnecessary, but much end of life care is palliative in nature and may not be intended to prolong life. Pain relief in a terminal patient may not be cost effective, but it's rather hard to argue against providing it.

Making sure that we don't pay for ineffective or unnecessary treatment is certainly important. But understanding why certain treatment may or may not be necessary is equally important.