• Americans don’t want government-based cost effectiveness in health care

    Cost effectiveness health care coverage decisions are part of governing in the United Kingdom, Italy, Germany, and Australia. It’s part of how those countries manage health care technology.

    We don’t do that in the U.S., though as Nick pointed out yesterday, PCORI certainly could. But, according to a new survey, Americans don’t want it to.

    Most of the overall study population opposed a government CER [cost effectiveness research] agency. About 56% of respondents would oppose such an agency []. Democrats and Independents were about evenly split on the issue, while a significantly smaller percentage of Republicans would support such an agency (26.9%). Younger respondents, aged 18 to 29 years, were significantly more likely to support an agency (64.7%) than respondents 65 years or older (31.2%). […]

    This study should offer a warning to the research community that, despite the cost-saving potential of CER, it is likely to engender widespread opposition when put into practice in the United States—particularly if decisions are widely known by the public. Growing health care spending will require smarter choices on the part of health care payers and consumers. This research suggests that the public often will not support the federal government making those decisions for them.

    What is not addressed in this survey is the extent to which Americans would accept non-government approach to CER. If, say, private plans made CER-informed coverage decisions transparently, would consumers voluntarily accept those decisions in exchange for lower premiums?

    It’s not enough to just say “no” and forget about this issue. At some point we will have to come to terms with health care technology. It’s a main, if not the main, driver of health care spending growth. It demands management, somehow, but, so far, we’ve acted as if we can have everything forever and at any price.


    • This is one of the most frustrating aspects to me of engaging with the public on health care. I can understand not wanting government to control that process. But, the question isn’t whether these decisions are going to be made. Someone somewhere has to say yes or no to a treatment, procedure, etc. The question is whether someplace along that decision-tree at least one person or organization considers the role of cost.

      If the answer to that is that costs can never be considered in health care, then we really are doomed to bad decisions.

    • Right now “the market” is making those decisions. If someone gets denied care because they don’t have enough money, that’s like an impersonal consequence of the rules, so people are all right with it. If there’s a panel that decides whether a thing is cost effective, it doesn’t matter that by definition it means they save other people who can’t afford to pay – it puts a face on the action and makes someone responsible. In real terms, though, the every-payer system kills several times more grandmas than the most prolific medical death panel could hope to.

    • Austin
      Also not in the study (see pdf supplement) is context. The survey poses questions unrelated to tenuous US health costs, fragility of system, and entitlement trade offs needed to sustain our budget.

      Asking whether you want steak vs hamburger as opposed to rent and not eating at all changes equation.


      • Without looking at the supplement, I’d say if it is asking questions in the context in which most Americans understand (or don’t) the issues, it’s highly relevant. If you educate them first with the poll, you don’t get a true measure of sentiment about this stuff. However, it leaves the hope that with education, the sentiment may change. (I’m skeptical.)

      • Hi Brad,

        On question-wordings, we based the phrasing on how these debates actually happened in the host countries. As Austin said, our goal was to avoid biasing respondents with the “academic” take on these decisions, but to be truthful to how they would actually be represented in public debate.

        The specific item wordings were vetted by experts in the HTA/CER bodies in the relevant countries to ensure they were accurate representations.

        -Mike (@michaelbotta)

        • Thanks Mike. Very kind of you to weigh in. I wish more authors would perform the same service.

          I still like to think US citizens special in the OECD schoolhouse. We are the ones sitting all the way in the back of the class, shooting spit balls, being held for detention, and missing the school trip.

          I think when our respective CER bodies vetted our versions of the questions, they had to key up MAD magazine instead of Hemingway for inspiration. I guess its too much to ask, “guns vs butter, you pick.”


    • Mike Botta,

      Excellent study. Very challenging for those of us in the HTA community.

      did you compare the response to Vignette 2 and 4 for consistency? Both vignettes look like they examine the weight attached to clinical expert opinion over formal evidence.

      I couldn’t tell from my admittedly quick read of the paper, if you tested for consistency of responses between these vignettes.


      • Hi Chris,

        I don’t have the correlations handy, but they were quite high across the board. It was definitely a surprise to us to see how consistently these decisions were opposed in the States.

        If it’s any consolation, when we compare results across countries (US responses to these vignettes vs responses in Italy, Germany, and the UK), the opposition to specific decisions is also high, even though those countries actually have functioning HTA bodies in place, and might have been the country in which the decision was actually made. But when you ask individuals in those countries about their satisfaction with the overall system, it’s much higher.

        Restricting access to any treatment seems as though it’ll always be unpopular when there’s also someone who stands to gain from its allowance actively discussing the potential benefits. But if it makes for a better-functioning health system, it’s a trade-off we should consider.

        • Thanks Mike. My interpretation of the two vignettes is that you have to attach contradictory weights to expert clinical opinion to object to both decisions. The not avastin for AMD vignette prefers the expensive therapy if expert clinical opinion does not outweigh the formal evidence. The not PET scanning vignette prefers the wider use of the expernsive imaging if expert clinical opinion outweighs the formal evidence. In which case you may be dealing with a lexicographical preference for complete freedom of choice from your respondents. So the conclusion I would draw is that the respondents preferences don’t help health systems choose between competing alternative uses of limited resources. The implication for health systems being they will get criticized whatever they do. The challenge then is to choose a decision strategy that is most able to be defended.

    • The problem with striving for a non-academic take on the questioning is that it begs the question of whether these polls and surveys have any real-world value whatsoever. It calls to mind the famous Churchill quote about the best argument against democracy being a five minute conversation with the average voter. Why would you base policy on the opinions of non-informed opinion holders in any field of human endeavor. And why would we or should we be deterred from pursuing rational public policy in health care based on the exhibited ignorance and/or cognitive dissonance displayed in this poll and many others? First educate the public on the exigencies of a realistic healthcare policy; then ask them to choose among the realistic alternatives. Do not ask them whether they prefer reality or pie in the sky; we already know what the response will be.

    • I wonder if people would be as opposed to a cost saving bureaucracy if it was like the quasi private body that regulates organ allocation in the US.

      David Weimer in the book Medical Governance talked about how the way that OPTN and UNOS are structured allows them to operate as trusted rule making organizations without being formal parts of the government.

      He made the case for making a body called MedSAVE (Medicare surgery Assessment Volunteers for Effectiveness) under either the Medicare Payment Advisory Commission or the Medicare Evidence Development and Coverage Advisory Committee. The whole thing would be modeled after the OPTN and use a similar decision structure, with the rules being formed by committees of doctors and other stakeholders.

      It might solve the problem outlined in the survey a little bit.

      The problem with the theory is that the genesis of the OPTN was from existing networks among transplant centers. Also, transplant centers, hospitals, and patients had largely the same incentives about who got organs so there was more room for cooperation. Whether you could find similar shared incentives among hospitals, doctors, insurers and patients is another story.

    • somehow, but, so far, we’ve acted as if we can have everything forever and at any price.

      Not surprising because most people do not even don’t even know how much their employer of Government pays for health insurance let alone what the insurer pays for the care!

      IMO we need much, much more out of pocket spending for the most capable distinguishable set of people, those with above median income.

    • I wonder if people would support CER if done by church owned and operated hospitals and by mutual aid societies.