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The Baltimore Sun has a good article on the state of play, and potential difficulties, for comparative effectiveness research. Max Baucus and Kent Conrad are expected to offer up legislation creating a CER board later this year, and it may well pass. But that won't be the end of it. Last weekend, I wrote a post suggesting that one of the many impediments to cost control were doctor's guilds. If my comments and inbox were any indication, that post pissed a lot of people off. But it's never more true than in decisions about which surgeries to use, and which treatments to cover. In the late 80s, the Bush administration created the Agency for Health Care Policy and Research, a federal agency meant to coordinate experts to evaluate evidence and help institutionalize best practices in medicine and help insurers, both private and public, make informed coverage decisions. In 1993, the AHCPR named 23 experts to a panel on treating lower back pain. Shannon Brownlee explains what happened next:
when the AHCPR's panel concluded that there was little evidence to support surgery as a first-line treatment for low back pain, and that doctors and patients would be wise to try nonsurgical interventions first, back surgeons went wild. They knew that once the AHCPR's guidelines were published, Medicare might limit reimbursement for various back surgeries to patients who were enrolled in a controlled clinical trial designed to test the efficacy of the procedure. If the study showed that a surgery was no better than nonsurgical remedies, or only about as good, there was a chance that Medicare would stop reimbursing for it. If Medicare made a back surgery provisional, private insurers were likely to follow.Sensing a threat to their livelihoods, many surgeons bombarded Congress with letters contending that the agency's panel was biased. One doctor, Neil Kahanovitz, founded the Center for Patient Advocacy, a nonprofit that orchestrated a sustained lobbying campaign against the entire agency. A company that manufactures pedicle screws (devices that are sometimes used during spinal fusion) sought a court injunction to prevent publication of the guidelines. The North American Spine Society, the main professional group for back surgeons, launched an assault on the methods used by the AHCPR experts, charging that the agency had wasted taxpayer dollars on the study.The surgeons found an eager ally in Newt Gingrich, who targeted the AHCPR for elimination. It was eventually saved by friendly Senate Republicans, but in a diminished form, with a reduced budget, which stripped the agency of its original mission and recast as a mere "clearinghouse" for data. In health care, lots of things don't work. Experts estimate that somewhere between 15 percent and 50 percent of treatment is utterly wasted. But in health care as in much else, one man's waste is another man's profit, and profit is protected. That's true for the medical device manufacturers, true for the pharmaceutical companies, and true, yes, for the doctor's guilds. The question is whether spending is so high, and the pressure is so great, that a new comparative effectiveness board will have powerful political defenders (like insurers and the business community) who will protect its mission and beat back those who would dismantle it out of self-interest. My sense is that the insurers are particularly strongly behind a CER board and that business increasingly realizes the importance of smarter care purchasing. Additionally, Newt Gingrich and his hordes aren't about to sweep to power with a 50+seat win in the House. But we'll see.
