Medical Inflation and Comparative Effectiveness

Back in the 1970’s Gerald Ford tried to fight inflation by having people wear WIN badges, standing for Whip Inflation Now. David Brooks (or possibly an editor at The New York Times) has applied the slogan to a column on  health care costs without even giving Ford credit. Brooks is generally correct that little that is being proposed will significantly lower health care costs, but there is one point where I disagree with his evaluation:

There are several ideas floating around that could reduce inflation, but they are neutered in the current bills. For example, many people believe that comparative effectiveness research would bend the cost curve. The current bills would pay for that research but negate the effects by allowing everybody to ignore the findings.

I know this sounds a bit strange, but paying for research on comparative effectiveness but leaving the ultimate judgement as to treatment up to the physician is exactly the right way to handle this. There are many areas where we have very poor data as to which treatments work best, such as with prostate cancer, despite tremendous differences in cost between various methods. If we had good data (which does not come from the pharmaceutical companies with a stake in the decision) such results would not be ignored. Doctors would be more likely to recommend the best treatment given the evidence. If doctors did not, plenty of patients would come in with data from the internet.

Such findings should not be mandatory. Practice guidelines which are relevant to most patients with a single disorder might not apply to patients with multiple disorders. Even studies which show that one treatment is generally best might find some exceptions. The preferences of the patient also need to be considered. In situations where there is a choice between long term medications and surgery, some patients might be reluctant to take time off from work, or be terrified by surgery. Other patients might be poorly compliant with medications, or have problems taking the medications, making a quick surgical intervention a better choice for them. Comparative effectiveness studies would be considered in making medical decisions, but they cannot provide the final answer.

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  1. 1
    Eclectic Radical says:

    One would think this would go without saying. Unfortunately, there appears to be a large gap in common sense floating around Washington on both sides of medical issues. The right claims to believe that rationing the care of Medicare recipients will stop rationed care. The left claims to believe that they can finance a public option simply by forcing companies that don’t provide insurance to their employees to pay for it for them. Both sides believe people who cannot afford insurance will be helped by a law forcing them to buy insurance.
    It’s a mad world.

  2. 2
    Ron Chusid says:

    I was hopeful when Obama actively campaigned against mandates during the campaign but that didn’t hold up. Once there are mandates it makes it far too easy to simply pass a law requiring insurance and declaring that we have universal health care regardless of whether the system really works. I don’t totally blame Obama. He simply had far too allies to continue to fight for this. Too few liberals agreed with him. Insurance companies want mandates making Republicans unlikely to draw a line in the sand here (even if they make noise objecting). People looking at details rather than the big picture will also like mandates as on paper it is much easier to design a program with mandates.

    Of course the devil is in the details. A big question will be how much money is really available to help individuals pay for coverage. For business the question will be how large a business will have to be to fall under the requirements and how big the payment is for not participating.

  3. 3
    Eclectic Radical says:

    The Republican plan to which I frequently reference, and to which I have provided links before, is as firm as the Democrats in believing in the virtue of mandates. Their mandate is funded even less effectively than the Democratic plan, by tax cuts meaningless (in proportion to the cost of health care) to the majority of American citizens. So not only are Republicans not going to draw a line, there is clearly ‘bipartisan compromise on health care’ to be had somewhere between ‘mandate insurance and kick everyone off medicare’ and ‘mandate insurance make business pay for it.’
    The problem is, whatever bipartisan compromise may come of such a narrow gulf, this is NOT effective or meaningful reform. This is why administration and Senate health reform plans are being criticized by the left. Because without a public option, the way they are currently written is not reform… it is simply requiring everyone to take part in the failed system whether they can afford it or not.
    So now poor people without health insurance won’t just be screwed, they’ll also be criminalized. 🙂
    Of course, I’m sure a plethora of cheap and affordable health insruance plans which provide no actual guarantee of meaingful care will come into being so everyone can be compliant with the law. But they will be worth about as much as the cheap liability plans that exist solely to allow drivers to be compliant with auto insurance mandates.
    If anyone on ‘the left’ is really threatening to kill reform, it’s Democratic Senators putting all their reform hopes on mandates to get insurance industry support.

  4. 4
    Ron Chusid says:

    “So now poor people without health insurance won’t just be screwed, they’ll also be criminalized.”

    They will receive assistance with coverage based upon income.

    “Of course, I’m sure a plethora of cheap and affordable health insruance plans which provide no actual guarantee of meaingful care will come into being so everyone can be compliant with the law.”

    The plan also contains regulations as to what an insurance must cover so they can no longer sell health insurance which doesn’t really cover anything.

  5. 5
    Eclectic Radical says:

    “They will receive assistance with coverage based upon income.”
    Yes, this is currently in the plan. If it remains in the plan and is not defunded as part of a compromise, then I won’t be out to kill the plan. A lot is negotiable at the moment, and the relatively small gap between the Senate Dems plan and CPR means that a ‘bi-partisan’ compromise could alter the assistance significantly.  I do think it’s important to comment on some of these facts and raise awareness of the relatively narrow line that we need to avoid crossing in order for reform to be meaningful. I think a lot of people are not informed of the line or how fine it is.
    “The plan also contains regulations as to what an insurance must cover so they can no longer sell health insurance which doesn’t really cover anything.”
    Yes, it does contain regulations. Whether those regulations, in the final plan passed, will be sufficient is an open question. I have a lot of faith in the good intentions of Teddy Kennedy, and am willing to make myself an open target for conservative jokes by saying so. However, he’s not the guy who will have the final say on any compromise plan that actually passes. There are Democrats (Ben Nelson comes most immediately to mind, but he’s not the only one) who feel very much as Republicans on many facets of paying for health care. The level of ‘bi-partisan’ compromise needed to gain their support could significantly cripple the plan.
    Again, if these regulations are reasonable I’ll be very willing to see the plan as a good, if small, first step… but I am very concerned about the regulations being compromised to a lesser degree of significance than necessary and feel it important, as noted above, to be clear about the fineness of the line.
    I think criticism of the process and the plans being kicked around is very important right now, and I really don’t want to see a toothless package passed and then trumpeted as a great victory for health care reform.
    I don’t feel I am being over critical, I believe I am calling attention to details about which people need to know and making an argument people need to hear that is not being argued sufficiently by people elected to make it. I’m happy to support a plan that provides meaningful improvement in the quality of care for Americans. Even if I am unhappy with the plan. I’m just not going to be uncritical of the process or the plan, even in supporting it.

  6. 6
    Ron Chusid says:

    The areas where compromise is being discussed (such as weakening or eliminating the public plan) do not include items such as assistance with heath care coverage and changing how the insurance industry operates.

    We may or may not get everything desired in health care legislation, but there are many things which would be of value on their own alone, such as eliminating the ability of insurance companies to drop people when they become sick, exclusions for preexisting conditions which limit ability to change insurance (and often employers) and assistance for those who now cannot afford coverage.

  7. 7
    Eclectic Radical says:

    If the compromise that we finally get goes the way you are predicting, then it will be a step in the right direction… a very small step, but a step. I’m just not as confident as you are that more will not come under scrutiny for compromise if deficit hawks on the Democratic side sink their teeth in deep and refuse to let go. I don’t believe that the Senate Dems will compromise for the GOP hardliners, not now, but they may need to compromise for Ben Nelson and Arlen Specter (as just two possible examples) on the Dem side in order to crack a potential filibuster. If they do, and the choice is no bill or a bad bill, I am not entirely certain they won’t take a bad bill and I think it is a mistake for anyone else to be completely confident or let up the pressure.
    Some of the purple Dems in the 60 vote majority are not necessarily reliable on the health care issue. We all remember Sam Nunn.

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