• Comparative effectiveness research as a public good

    In Health Affairs, Alan Garber offers a framework for comparative effectiveness research (CER) that the Patient-Centered Outcomes Research Institute (PCORI) could adopt. Along the way, he makes the case why government should lead the CER effort.

    [E]ven though such research [if conducted by private insurers] is often helpful to providers and patients, they may view even well-designed, well-reported research with mistrust when it is sponsored or conducted by payers and other organizations perceived to be acting in self interest.

    The diversity of US comparative effectiveness efforts had other important drawbacks. The research was at best loosely coordinated and often duplicative. Also, attaining sufficient scale to achieve the most ambitious aims was difficult. For example, few private entities supporting comparative effectiveness research could sponsor large-scale, expensive clinical trials. Furthermore, there was no uniformity in research methods, rating standards, assessment approaches, or reporting.

    In addition to these arguments, it’s clear that CER is a public good. Plans aren’t motivated to sponsor their own research because whatever advantage might be gained by it would be hard to protect from rivals. It’s also not clear private plans can effectively operationalize CER without a large public insurer, like Medicare, taking the lead, if only for legal cover.

    With this, you can begin to see an argument for supporting traditional Medicare and its use of CER for coverage and/or payment decisions. To be sure, this is a political challenge. But what is the alternative? Whatever it is, it would be some other legal infrastructure and research enterprise that would solve the collective action problem and provide legal safe harbor to private plans wishing to make CER-based coverage decisions. I have not seen any advocates of a private-plan replacement for Medicare articulate what that framework would look like. Have you?

    We pay a lot of lip service to the idea of not using public (or collective) funds for care that does not improve health. Rather than bluntly cutting payment rates or shifting costs to individuals for procedures without regard to their clinical value (something value-based insurance design aims to avoid), a smarter way is to trim the fat. The trouble is that much of it is marbled throughout the system, not far from muscle and bone. CER is the only way I know of to identify where and for whom it exists.

    Chandra and Skinner’s typology of health care technologies is a useful framework to guide the effort. Alan Garber fleshes out the process. Together, these make for a good start, but we need more. We need a large payer to take action on CER-based evidence. It could be Medicare. Could it be anything else?

    • I thought over this post last night. I think it is an important post, but not particularly sexy so most people will not pick up on it. It does bring up a question that has, sort of, puzzled me. CER, of a sort is common in many other industries. You can find data on many products comparing their cost, how well they work and how long they will last. This uncommonly happens in the health care industry. Why not? I have my own ideas, and you have covered this at least tangentially, but if we wish to employ market reforms in any form or shape, dont we need to understand why this is not happening spontaneously like it does in other industries?


      • I too think this is far more important than many will recognize. If you can think of ways to sex it up, let me know.

        Why is this not happening? I think there is a collective action problem combined with a general state of opacity of costs and quality to the consumer. Toss in the political and legal factors and there are tremendous disincentives for plans and the public to invest and abide by the results of CER. It’s also true that it’s a moving target. It takes years to amass evidence about effectiveness. By that time, the interests are entrenched.

        Finally, a lot of health care caters to hope. Who with a serious illness wants to give that up?

        • @Austin and Steve
          it is cultural fear of death and inability to face limits. Health care is viewed differently by people. I think only hope is to start trying to practically apply CER and link it with tax based fail safes. Then the question can be focused to if you want to spend on things that don’t work we have to pay for them. Politically seems impossible, but only way imaginable is focus on pop like dual eligibles or medicare generally for a given disease (say) CHF and then start making a list of we always pay for this, we by default pay for this, you have to make the case, etc. I think my main point is the only way to sex it up is to actually apply CER for coverage decisions. Of course then it goes from unsexy to defcon 5.