Every lobbyist swarming Capitol Hill these days knows that, when it comes to legislation, the devil is always lurking in the details, not lounging in the concepts. Yet concepts, not details, are drifting down to the public—who will be in for a surprise when they realize that reform is not what they think it is. How these details are hashed out, or slipped into a bill at the eleventh hour is crucial to the success or failure of reform. This is the sixth of a series of occasional posts that will look at where the devil lies in key provisions of the health care bill. The entire series is archived here.
Bill Clinton’s heart stents gave Fox News a chance to take a whack at health reform. This time the issue was comparative effectiveness, which means systematically comparing, based on scientific evidence, how effective two or more treatments are in treating disease. While this sounds straightforward enough, comparative effectiveness is not a slam dunk. Supporters promise that it will save money, a prediction that may or may not come true. Some doctors, who are used to raking in big bucks from ineffective treatments, aren’t keen on the idea. Neither are right-wing ideologues who use comparative effectiveness to invoke the specter of rationing and to whip up hysteria against reform in general. Pity the poor patient denied some advertised life-saving treatment, even if its efficacy is questionable!
That’s the line that Fox took the other day, implying rather clumsily that the former president might not have gotten his stents if the Democrats’ health reform “had gone through.” Fox & Friends host Brian Kilmeade got right to his point by asking the network’s legal analyst, Peter J. Johnson, Jr., if Clinton would have gotten his stents. “I do think under a lot of protocols, he would have gotten those stents,” Johnson replied, and then quickly moved to the “what if” part of the conversation. He cited the sums the government plans to spend on comparative effectiveness research—the $1.1 billion called for by the stimulus bill and the nearly $300 million requested in President Obama’s budget—which could create, he said, “best practices, a standard of care.” Johnson went on, getting in his licks about the Obama crew:
If the government decides to adopt the Peter Orszag, budget director, architect of health care, method and put in regulations that say there is a gold standard, there is a best practice based on the literature, perhaps hundreds of thousands of people like the president.
The host interrupted here, and the conversation centered for a moment on a Wall Street Journal story from last week, about a study showing that, generally, stents offer no additional benefit when used with a cocktail of generic drugs for patients who have chronic chest pain. Johnson and Kilmeade chatted about the study, and Johnson had the last word, which couldn’t help but cast doubt on the comparative effectiveness movement:
If the new standard is save money, best practices—does President Clinton or you or I who needs it—get the stent under that new regimen of health care effectiveness?Fox missed the real point of the Journal’s very good piece: studies, like the one for heart stents, “that find an already-popular and a lucrative treatment can merely be unnecessary, but not harmful,” have rarely changed medical practice—unlike studies showing that a particular treatment, such as hormone replacement therapy, can actually be detrimental. Journal reporter Keith Winstein used heart stents as an entrée to show how a procedure that costs the U.S. $15 billion a year continues to be used because it satisfies stakeholder interests—cardiologists who get paid roughly $900 for doing the procedure; insurers who fear a crackdown on stenting would mean employers would take their business to other carriers that are more loosey-goosey about spending; patients who don’t care about the cost because someone else is paying, and may take their business elsewhere if a doctor doesn’t accede to their demands.
That’s why comparative effectiveness faces a tough battle for respectability. Fox missed another important point the Journal made. Comparative effectiveness provisions in the bills passed by the House and Senate allow researchers to disseminate their findings, but don’t require insurance companies or Medicare to base their coverage or payments on them. A few weeks ago I sat down with Jeffrey Lerner, who heads the ECRI Institute, and knows a thing or two about evaluating medical technology and the evidence. Lerner explained that the bills would establish an institute or a center to identify research priorities and conduct the studies, but the findings cannot be used as mandates, guidelines, recommendations for payment, or to deny coverage. Fox News: Take note!
Such prohibitions raise questions about how any of this research might translate into actual medical practice and benefit patients, and they show how the whole idea of comparing treatments got watered down in the legislative give and take. Lerner talked about another thorny issue: cost effectiveness, which looks at how well a particular treatment works for the amount of money there is to spend on it. “You don’t see any language about cost effectiveness,” said Lerner. “That was removed.” In other words, any notion of cost effectiveness vanished a year ago when the stimulus package made its way through Congress.
Few stories have delved into this devil lurking in the details. Kaiser News Service offered a summary of the issue, noting that a group, the Partnership to Improve Patient Care, headed by former congressman Tony Coelho, opposes using comparative effectiveness research for coverage decisions. That’s a group to keep an eye on should health reform start moving again. The Sacramento Bee brought the story home and talked about a local orthopedic surgeon who conducted his own study to find out if a certain procedure actually worked. It was an interesting journalistic approach.
There’s plenty here to explore to counteract the misleading reporting from the likes of Fox News.