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.