This month’s post comes
to us from past president of ACC’s Virginia Chapter, John Brush, Jr., M.D.,
F.A.C.C. In addition to serving three years as Chapter president, Dr. Brush
practices at Cardiology Consultants, Ltd., in Norfolk, Va., and is an Assistant
Professor of Clinical Internal Medicine at Eastern Virginia Medical School. He
also has been a leader in quality improvement, assisting ACC efforts with “Door-to-Balloon:
An Alliance for Quality” and the IC3
Program, and as a member of ACC’s Clinical Quality Committee.
the current health care reform debate, there has been considerable discussion
about comparative effectiveness. This
method of evaluation could provide valuable information on the relative value
of competing drugs, devices and treatment strategies, which in turn could
improve outcomes, efficiency and satisfaction. Critics are concerned, however, that comparative effectiveness could be
used to deny coverage, squelch innovation and ration care. Because of these concerns, some stakeholders
forcefully argue that comparative effectiveness evaluations should be totally
devoid of cost considerations.
how can you compare competing treatments and ignore costs? To use heart failure as an example, could you
really compare the relative effectiveness of ACE inhibitors and left
ventricular assist devices and ignore the wide difference in costs between the
two treatments? And isn’t the public’s desire to gain “more bang for the buck”
what’s driving health care reform in the first place?
The Case for Cost
effectiveness research is difficult and has recognized limitations. Yet no method of research is perfect or
definitive. Although cost effectiveness research has some limitations, we
should not reject the useful information that it provides for comparative
is a compelling need to contain costs in order to extend health care coverage
universally in America. Comparative
effectiveness research will give policy makers important information that will
help set priorities for spending. As
with clinical practice guidelines, comparative effectiveness analysis should
inform, but not dictate clinical decisions.
Personalized decision-making for individual patients should always trump
broad policy recommendations.
Comparative + Cost Effectiveness
effectiveness research and analysis will require a disciplined approach. Comparative effectiveness research should be
a transparent scientific process, absolutely free of economic influence. Advisory boards that oversee this research
and analyze the results should be shielded from undue political influence. For years, NIH has distributed billions of
dollars in funding, using established methods that are generally respected as
fair and non-biased. Similar
independence and discipline can be established for overseeing comparative
effectiveness research and analysis.
effectiveness research using cost considerations should be a two-stage
process. The first stage should pertain
to relative clinical effectiveness and the second stage should deal with
costs. For competing treatments with
similar clinical effectiveness, no further cost effectiveness research is
needed because direct cost comparisons would be simple. But in comparisons where one treatment is
more effective, careful analysis of costs will be necessary to estimate the
monetary value of the increased effectiveness.
Constructing a Firewall
against Undue Influence
maintain the integrity of this process, and to shield the process from
political and financial influence, a firewall should be constructed between
comparative effectiveness evaluation and insurance coverage decisions. The funding level for coverage is a political
or a business issue, not a scientific issue.
The funding level for Medicare is up to Congress, and, ultimately, to
taxpayers. The funding level for private
health plans is up to the purchasers and benefit design managers.
effectiveness analysis can be separated from coverage decisions by borrowing
the method used in the process of grant funding:
judging grants, the judges evaluate the grants based on the scientific merit of
the grant, without consideration of whether the grant will actually receive
are graded on a relative scale.
grants that fall within the funding range receive a grant.
that rationing? Perhaps so, but this
explicit method of determining coverage seems more rational than the current
method for rationing where we deny care to nearly 50 million Americans because
they lack employer-based insurance or don’t meet the criteria for Medicare or
device and pharmaceutical industry is predictably worried about comparative
effectiveness. Undoubtedly, comparative
effectiveness would provide pressure on pricing, which is generally lacking
when providers and patients pass on costs to third party payers. Transparent
comparative effectiveness would give consumers of health care an opportunity to
shop for greater value, which will help contain overall costs.
We Can’t Have it All
is the unfortunate truth: the growth in health care spending is unsustainable
and is making health care unaffordable for average Americans. In health care, we can have nearly anything
we want – we just can’t have everything we want. Because of escalating costs and limited
funding, we need mechanisms to differentiate medical treatments with high value
and those with little incremental value.
Without a method to objectively analyze the relative value of
treatments, the costs of medical care will continue to rise to unaffordable
John E. Brush, Jr., M.D., F.A.C.C.
* Dr. Brush’s post is
part of a monthly series of guest posts by ACC
leadership. Check back next month to see which ACC leader is sharing his or her
thoughts on health care reform!
*** Image from morgueFile (jdurham). ***