Friday, February 13, 2009

Government funded comparative effectiveness project-mechanism for rationing or,boon to special interests or neither

To some,the allocation of 1 billion dollars to a government project to evaluate comparative effectiveness represents a danger, the specter of a mechanism to ration care and cut costs, and cast a big brother eye of physicians' practices glossed over with the veneer of scientific research. Others fear the capture of the government mechanism to further the special interests of various interested parties, such as drug and medical equipment companies. and to provide third party payers a rationale to limit payments.Others see the potential for unbiased, transparent research that could lead to better information for practicing physicians and a resultant improvement in medical care.

Dr. Roy Poses offers a thoughtful discussion of these issues here.

George Will talks about the Council of comparative effectiveness research (CER) here.

It is hard to ignore the possibility that at least one of the reasons for the existence of the council of CER might be to save money and limit Medicare expenditure-even if indirectly- as illustrated in this quote from Will's commentary.

The stimulus legislation would create a council for Comparative Effectiveness Research. This is about medicine but not about healing the economy. The CER would identify (this is language from the draft report on the legislation) medical "items, procedures, and interventions" that it deems insufficiently effective or excessively expensive. They "will no longer be prescribed" by federal health programs. The next secretary of health and human services, Tom Daschle, ( Written before Daschle declined the nomination) has advocated a "Federal Health Board" similar to the CER, whose recommendations "would have teeth Congress could restrict the tax exclusion for health insurance to "insurance that complies with the Board's recommendation." The CER, which would dramatically advance government control -- and rationing -- of health care, should be thoroughly debated, not stealthily created in the name of "stimulus."

Bob Doherty, The American College of Physicians' man in Washington, expresses the opinion that rationing is not the reason behind the bill and that it is really about "giving physicians and patients transparent and evidence based information to make their decisions."

That conclusion seems inconsistent with Will's quoting from the language of the bill ,although there is some doubt about exactly what the actual wording is, see below . Doherty argues further that the assertion that the council's decisions will lead to micromanagement of medical care as stated in a Wall Street Journal commentary found here cannot be true because the ACP favors the project. (There must be more to his argument that it seems-is he not simply saying it will not lead to micromanagement because the ACP says it won't).

In a second related posting, Doherty charges that the bill is mis-characterized in the widely read and quoted Bloomberg article by Betsy McCaughsey.He asserts that the bill does not create or empower the agency to make decisions to limit care,will not monitor physician's care nor mandate appropriate therapy. I wonder if CMS might find the CER's findings useful in their activities to control costs.

Another aspect of the CER matter is the issue of regulatory capture which I talked about here.

To muddy the waters even more, see this notice by Media Matters that asserts that the language of the bill does not in fact actually say federal health program will not pay for certain programs based on the CER analysis. We will have to wait a bit to clarify exactly what the bill says.

To the extent that the bill reflects the views expressed in Daschle's book on health care, cost containment will be on the table.See here for some comments about what his views are on that subject. Yes, I know Daschle won't be the health czar but will the views of the health wonks that wrote (or at least helped write) his book prevail.

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