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What Happens When Doctors Ignore Effectiveness Research?

You can't just force cookie-cutter medical care on people.

By Will Offensicht  |  March 26, 2010

"Comparative Effectiveness Research (CER)" is a major part of the Obamacare bill by which the government plans to take over our health care system.  It sounds like yet another meaningless acronym.  Would that it were so!

The idea of CER is extremely plausible on its face.  The plan is for knowledgeable doctors to examine all the available data, determine which treatments are the most effective for various diseases, and publish the results.

Once other doctors know the most effective way to treat any given disease, the theory goes, they'll switch from ineffective treatments to more effective treatments and we'll save a lot of money.  Isn't applying "best-practice" across the board simple common sense?  After all, it's worked great in manufacturing.

The first major flaw in the theory is that it's quite difficult to determine the most effective treatment and even if you do, the conclusions might not be acceptable to the public.  The recent dust-ups over mammograms, vaginal delivery versus Caesearian sections when giving birth, and prostate examinations show that popular acceptance of the results of CER is a necessary factor in actually cutting medical costs.

Voters are not products on an assembly line; unlike, say, a Chevy, they care about what is done to them and why.  A woman who's convinced that she might die a gruesome death without a mammogram is not going to be satisfied by a panel of doctors saying "Statistically speaking, there's really no need" no matter how august the scholars who made the determination.

Doubts about PSA testing to diagnose prostate cancer didn't get nearly as much publicity as the mammogram controversy, but the issues are just as fraught.  Earlier surgical techniques for removing cancerous prostates ended up cutting important nerves that run through the same neighborhood as the prostate.  Men lost the ability to achieve erections when these nerves are damaged.

Men care about getting erections nearly as much as women care about their breasts and about giving birth.  Any study which tries to affect behavior regarding these matters must take patients' views into account.

What if Patients Don't Care?

The second major flaw in CER is that doctors won't always accept its conclusions even when patients don't particularly care.  The idea of studying medical treatments didn't originate with the Obama administration; the Wall Street Journal reminds us that the concept has been around for years.

It sounds like such a simple concept: Study different medical treatments and figure out which delivers the best results at the cheapest cost, giving patients the most effective care...

Yet, an examination of one of the best-known examples of a comparative-effectiveness analysis shows how complicated such a seemingly straightforward idea can get.

The most common heart surgery is a $15,000 procedure to insert a small metal brace called a stent into an artery to open up an obstruction.  In 2007, the New England Journal of Medicine published a study which had followed 2,287 heart patients for 5 years.

The study found that trying drugs first and inserting a stent only if chest pain persisted didn't affect the death rate from heart attacks, although installing a stent gave faster pain relief.  The study was regarded as a blockbuster, and stock in Boston Scientific Corp. fell the next day as investors expected stent use to diminish in the light of the study.

While stent use fell 13% the month after the study came out, stent use recovered to the same level as before once the headlines faded.

"Most [cardiologists] haven't voluntarily incorporated the Courage criteria into their practice," says Dr. Boden [who led the study]. "What's going to continue to drive practice is reimbursement."...

The average cardiologist who installs stents made about $500,000 in 2008, up 22% from 10 years prior, adjusted for inflation, according to the American Medical Group Association.

This shows yet again that the most important aspect of a medical treatment is whether it's covered by insurance: patients don't care what a procedure costs when they aren't paying for it.  Doctors get about $900 by recommending a stent instead of just getting paid for an office visit and writing a drug prescription.

Existing laws don't help either:

Under federal law, Courage's findings about efficacy can't alter the amount Medicare pays doctors for stenting. The government insurance program is legally barred from considering a treatment's benefits when deciding how much to pay doctors for doing a certain procedure. Private insurance carriers, in turn, generally base their rate schedule on Medicare's.  [emphasis added]

At more than 2,700 pages, Obamacare is so complicated that, according to Nancy Pelosi, they had to pass it just so we can find out what it says.  Given the large number of pressure groups who needed to be bought off, it's difficult to believe that the new law will do anything to change the underlying financial incentives that drive medical costs.

Unless these primary cost drivers are addressed, the only way to cover more people will be to spend more money.  What will happen when costs continue to explode?  Will future CER conclusions be accepted any better than past studies?  Only if they're made compulsory, of course, because doctors make too much money to give up lucrative procedures without coercion just because they're ineffective.

Polls show that most Americans believe that Obamacare will drive up medical costs and that they will receive less effective medical care.  Given the long history of Medicare being forbidden to consider a treatment's effectiveness when setting reimbursement rates, their concerns are clearly well founded.

If not passing Obamacare meant that we'd never find out what's in it, that would have been an extremely reasonable price to pay to dodge this monstrosity.