If you are sick and seek medical help, you probably expect that your doctor will choose the most effective treatments from different alternatives, and that the choices will be based on solid evidence. But American health care providers make far too many decisions based on force of habit or financial gain.
Fortunately, Congress took a little-noticed, important step in the Affordable Care Act to rectify this problem by funding comparative-effectiveness research, which uses data from clinical trials and real-world treatment settings to determine which health care practices are the most effective. But the promise of CER still might be dashed by special interests and a medical establishment that is too slow to change.
Time to Stop the Waste
America's hospitals, doctors and insurers need to step up to the plate and do much more to incorporate this research into health care delivery, even if the health care act eventually is repealed or dismantled.
Last year, between $158 billion and $226 billion were spent on medical procedures that had no value, according to Donald Berwick, the former administrator of the Centers for Medicare & Medicaid Services, and RAND Corp. researcher Andrew Hackbarth. Much waste comes from treatments that cost far more than equally effective — or more effective — alternatives. For example, research shows that treatments for prostate cancer that use expensive proton beam radiation equipment are no more effective than radiation therapy, which costs much less.
Other examples abound. Even physicians with the best of intentions lack sufficient evidence to help them choose from a wide array of treatment options available for many problems. Frequently, they fall back on customary care, which means the often-unacceptable status quo.
Comparative-effectiveness research is not a cure-all for these problems. But it provides vital new information on procedures whose effectiveness has been evaluated in the highly controlled environment of clinical trials, where either a treatment or a placebo is assigned to a narrowly defined group of patients. CER also evaluates procedures that have not had clinical trials.
While health providers have been slow to embrace evidence-based medicine, some, to their credit, have begun to take it more seriously. Working with the American Board of Internal Medicine Foundation and Consumer Reports, nine medical specialty groups recently publicized a list of 45 tests and procedures that are used often, but that evidence indicates are unnecessary or inappropriate.
Up Against Financial Interests
When the Patient-Centered Outcomes Research Institute (the institute that was set up to oversee CER) releases its findings, it will almost certainly run afoul of medical specialists, medical device manufacturers and pharmaceutical companies, who clearly have a vested economic interest in high-cost treatments and diagnostic techniques. Indeed, when funding for CER was proposed in 2009 as part of the federal stimulus bill, medical device-makers and the pharmaceutical industry lobbied against it.
Countering them requires weaning physicians and hospitals from procedures that are lucrative but not always in the best interests of patients, which will mean readjusting their economic incentives. That will be a complex and politically difficult process, but it can and should be started now, with the cooperation of the health care establishment and public and private insurers. For example, Medicare now covers care deemed to be "reasonable and necessary" without regard to cost. It should be free to use new evidence from CER to redefine the "reasonable and necessary" standard. So should private insurers.
America's hospitals and doctors also can help by changing the way physicians are evaluated by their peers. Right now, peer review in private American hospitals tends to judge whether physicians provide care based on the standards of customary practice, not evidence-based medicine, as noted by health law expert Katharine Van Tassel in a Health Affairs blog on July 3, 2012 ("Harmonizing the ACA with State Tort and Licensure Systems and Hospital Peer Review"). Incorporating CER-based standards into these evaluations would go a long way toward improving care.
Still, habits die hard. Perhaps the most important task for the health care industry is to educate medical practitioners at every stage of their careers about new findings yielded by CER. It will be up to medical schools and hospitals to ensure that this information influences physicians' recommendations and directly benefits patients.
Even if elected officials succeed in dismantling the health care act down the road, continued federal support for CER could improve Americans' health while cutting health care costs. But this can happen only if its conclusions are integrated more thoroughly into the decisions America's health care providers make every day for their patients.
Vivian Ho, Ph.D., is the chair of health economics at Rice University's James A. Baker III Institute for Public Policy in Houston. She is also a professor in the department of medicine at Baylor College of Medicine in Houston.