DO WE REALLY NEED TO DEFEND THE VERY CONCEPT OF "EVIDENCE?"

I don't really like writing defenses of "comparative effectiveness review." It makes me despair for our country. We're literally talking about the process of gathering evidence so we know how well various medical treatments work. It's worth saying, however, that there are two types of objections to gathering evidence, and they're being unfortunately conflated.

The first is the ideological objection. Some conservatives worry that the "the type of information collected by CER could eventually be used inappropriately if a 'Federal Health Board' was created to decide which types of treatment would be available to whom and when." It's worth parsing this for a moment: The apparent fear here is that the evidence from comparative effectiveness will be, well, used to make treatment decisions. But that can't be quite right. We use evidence all the time. Your insurer won't pay for a leg amputation when your symptom is a headache. Medicare doesn't cover a wheelchair if you're diagnosed with acute constipation. No one whines about that.

The fear, rather, is that the existence of more evidence will somehow qualitative change the way government uses evidence. The government will decree, in other words, that their testing shows back surgery ineffective, and back surgery is now illegal. Put slightly differently:

Step 1: Comparative effectiveness review.
Step 2: ????
Step 3: Authoritarian medical system

It's sort of what would happen if you applied The Road to Serfdom to the comparative effectiveness debate.

The industry's fear is quite different: This is the profit objection. Right now, most research on, say, drug effectiveness is funded by the pharmaceutical industry. That presents obvious advantages for them and problems for us. The concern here is that if they cease controlling the flow of evidence, then new studies will show that certain treatments don't work. For instance: Claritin goes off patent. Generic versions emerge. They're very cheap. Claritin's manufacturer changes the chemical composition slightly and comes up with Clarinex. They apply for a new patent. They sell it at a heavy mark-up. But it probably doesn't work much better. If there's credible evidence out there showing that it doesn't work much better, that's the end of that business strategy.

But this is the debate. Supporters of comparative effectiveness reform want information on whether medical treatments work. Some conservatives are worried that the government will take that evidence and use it to craft a totalitarian health care system. They are worried about anything that could further empower government. Some members of the medical device and pharmaceutical industry are worried that the existence of that evidence will reduce their profit margins. They are worried about anything that would hurt profits. But what's important about these objections is that they have nothing to do with comparative effectiveness review. Conservatives don't want to empower government. Industries don't want to sacrifice profits. This is an argument over principles that's simply taken the form of an argument over policy.

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