Friday, November 20, 2009

Health care re-form XV (RIP CER)

The August 15th blog entry, 'Health care re-form (Effectiveness)', poured some cold water on the notion that implementation of comparative effectiveness research would have the predicted ability "to bend the cost curve downward." Not because of any inherent problem with the notion of comparative effectiveness per se, but because the parties coming out on the short end (whether real or perceived; whether financially or health-wise, etc.) would agitate against implementation of the recommendations, and (based on the historical evidence) they would find some politician all too eager to take up their cause... This because most politicians often legislate "by sob story," and usually stampede to pass legislation "so that no other family will have to go through this pain..." (Note: by its nature comparative effectiveness research would say that it does not make sense to spend the money until it effects X families, X being a larger number. However, for most of our legislators X can be just one of their constituents, especially if it is a child, or other photogenic person, etc.)

The obstacles to change become even more insurmountable when the results of research goes contrary to the received wisdom of the day, because then resistance to the new suggestions will arise among many additional parties e.g. the physicians, "activists' of various stripes, and/or the public... An excellent example of this is the kerfuffle about the utility of mammograms, which kicked off this week.

This started when the U.S. Preventive Services Task Force (USPSTF) reviewed and revised its 2002 recommendations re breast screening (see graphic above, and see here)... What is the USPSTF and who sits on it ? From the USPTSTF fact sheet here, "The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services. The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care." The panel's members may also be seen at the link, which also has information regarding the background, mission, and work of the panel...

The outcry was immediate. Perhaps "primed" by the current debate over health care reform, people rushed to express their viewpoints, usually without bothering to review the process, research, or the science on which these new recommendations were based! Health care reform opponents (or at least the version proposed by the Democrats) rushed to label this as government cost-cutting, e.g. see here. The implication is that the task force members are government stooges, while in actuality they are "... 10 members, who bring expertise from the principal primary care specialties--family medicine, internal medicine, obstetrics and gynecology, and pediatrics-- and from the analytic sciences..." and "... the work of the Task Force is supported by scientific staff at the Office of Disease Prevention and Health Promotion in Washington, DC, and by a network of experts on preventive medicine and specific clinical topics throughout academia, the Federal Government, and the medical practice community." Beyond the 'anti-reform' folks, the "activists' also weighed in, rushing to join current adversaries in denunciations of the panel and its recommendations.

Politicians of all stripes and from both parties sounded off. The administration rushed to insulate itself from any adverse fallout, with HHS Secretary Kathleen Sebelius issuing a statement emphasizing that this came from "an outside, independent panel," and that much more research is required on the subject... The spokeswoman of America's Health Insurance Plans (AHIP, the lobbying group for the insurance industry) said that coverage would not change, and in a survey of 600 physicians 78% said that they did not agree with the new guidelines (one wonders based on what) and that they would not change the advice they give to their patients...

The bottom line: when research results bump up against peoples' hopes, fears, feelings about something as intimate as their health, most often the research will lose, at least in the short term. This is especially true if the research goes in the direction of reducing the availability of treatments. Not a good augury for the future success of comparative effectiveness research...

Mammogram Cutbacks – Make No Mistake, Rationing For Women Has Begun
Secretary Sebelius Statement on New Breast Cancer Recommendations
Majority of Doctors Do Not Agree With New Government Recommendations for Mammograms

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