• Cutting off your nose to spite your face

    Paul Krugman highlights the current thinking of many people on comparative-effectiveness research as written by Gov. Huckabee:

    Tucked away in the $787 billion stimulus was the establishment of the Federal Coordinating Council for Comparative Effectiveness, which will become our version of Britain’s National Institute for Health and Clinical Excellence, the ironically and Orwellian-named NICE. NICE decides who lives and who dies based on age and the cost of treatment. So the stimulus didn’t just waste your money; it planted the seeds from which the poisonous tree of death panels will grow…

    Who will get rationed? Well, the very old and the very young, obviously, the most helpless and vulnerable among us.

    This is frustrating.

    It baffles me why people are opposed to “comparative-effectiveness” research. “Comparative” means we want to, well, compare things. “Effectiveness” signals we are interested in how well things work. When we say “comparative-effectiveness” all we mean is that we want to compare how well things work.

    Full stop. That’s it.

    In essence, all research is “comparative-effectiveness”. Even when we compare a drug to placebo (or nothing), we are comparing the effectiveness of two alternatives. What’s confusing in all of this is that – right now – most funded research is against placebo. Hard as it is to believe, little is done to compare two therapies to each other. That’s why some want to explicitly do more of this.

    Cost is nowhere in this. It’s not “cost-effectiveness” (which I also support). That’s somehting different.

    The major rationale for this “comparative-effectiveness” is that we might find out that something works better than something else.  That’s all. I imagine most people would like to know that.  I don’t know why someone wouldn’t.

    I admit, if we find out that something works better (through the “comparative-effectiveness” work), AND it also turns out it’s cheaper, I’d encourage its use. I think that when something is more effective AND costs less, it’s a no brainer that it’s a superior option. But that’s not the point of “comparative-effectiveness” nor of any of the legislation that supports it.

    Moreover, if you just feel like “comparative-effectiveness” is the slippery slope to death panels, then I don’t understand how any research at all isn’t on the same slippery slope. After all, any research which shows a therapy doesn’t work could lead to its not being paid for. Any research could lead to rationing of things that don’t work. Should we abandon all research?

    But it’s the last line of the excerpt above that’s the most bizzare to me. Personally, I would love to know if some expensive therapies are less effective than cheaper ones. We all know we need to slow spending, and if we need to spend less, this seems like a great way to trim the fat.

    If we don’t, then we will run out of money and just have to spend less, period. We’ll have to ration.  What will get rationed? Medicare and Medicaid, obviously, or the very old and the very young, the most helpless and vulnerable among us.


    • Scientifically more knowledgeable people than you or me have raised grave scientific objections to the foundations of “comparative effectiveness,” even without the further complication of putting the “comparative effectiveness” tool in the hands of bureaucrats. See Bruce G. Charlton. Journal of Clinical Epidemiology 1996; Vol. 49, No. 6, pp. 623-626, available ungated at http://charltonteaching.blogspot.com/2010/10/scope-and-nature-of-epidemiology.html.

    • @Sam Schulman,

      I’ll ignore the slight and just say that I see no mention of comparative-effectiveness in that paper.

      Also, please tell me what the “grave objection” is to the ALLHAT study.

      Moreover, setting aside money so that researchers can conduct such work is not “putting a tool in the hands of bureaucrats”.

    • What is really happening here is that the politicians are acting on behalf of the medical industry (who pay directly for these political services) to block any attempt to reduce payment for ineffective and overpriced medical care. Comparative effectiveness research has the potential to reduce the profits of the medical industry. The debate uses inflammatory terms like “death panels” and “rationing” but it is really about allowing continued profits from ineffective (even harmful) medical procedures.

    • It’s sad to argue about conspiracies or who’s funding which position – in fact both pharma and govt has an obvious incentive to “rationalize” treatment in ways that are disadvantageous to patients because they depend on the fiction that the ‘science is settled; – which it seldom is. The way to oppose the monopolistic instincts of govt. and business (and medicine too) is to prevent them from colluding with one another through free-market means. Many decisions de haut en ban on what care is “overpriced” or “ineffective” turn out to be unreliable; even when they are not they prevent innovation and improvement.

    • Sam,
      I’m not sure I understand. Pharma’s goal is to sell more drugs at higher prices whether or not they are good for patients. Government bureaucrats are charged with providing health services to improve population health. Government doesn’t get rewarded for damaging patients like pharma does. Government is given a mandate and a budget. They get no reward for spending less and damaging patients.

      It also sounds like you are saying that all comparative effectiveness research is worthless so we shouldn’t even try. There is a lot of good CE research which if applied uniformly, would improve health and lower costs.

      I also don’t look forward to being treated by a doctor who wants to be innovative rather than one who follows the best scientific evidence. I believe that we have a good mechanism for innovation which is the “controlled trial”. I don’t want to be treated by doctors who think they know better performing uncontrolled experiments on me.

    • ” in fact both pharma and govt has an obvious incentive to “rationalize” treatment in ways that are disadvantageous to patients because they depend on the fiction that the ‘science is settled;”

      The same could be said for physicians. We can make more money if rationalize treatments that are disadvantageous to our patients. Same thing for researchers. On that basis, we should not trust anyone or any research. Fortunately, that is not how we work.

      “through free-market means.”

      Without the research, how will we know what works? If, as Austin pointed out, you can have equivalent results at 1/5 the price, wouldnt we want to know that? Why is ignorance an essential part of free markets. I dont remember that in Smith, Friedman, Hayek or Rothbard.



    • Yada, yada, yada…

      And the next thing you know, they’ll start outlawing hip replacements for anyone over the age of 26:

    • Don’t like NICE? Ever looked at it? Look up, for instance, the guidance sets around colon cancer. See if that looks like death panels and mindless rationing or an attempt at sound policy in a complicated world. …

    • I, too, can’t imagine how difficult practicing medicine would be without appropriate CER to reference on a patient-by-patient basis. I certainly look to my physicians to provide me their best guidance on treatments that will offer me the greatest potential for improved health when I find myself in the position of needing something beyond normal diet and exercise. Whomever funds honest and, by extension, valuable CER, should e commended.

      My family has one member who is in the unenviable position of now having to deal with metastatic melanoma. While we were fortunate enough to be enrolled in a clinical study of a promising new targeted therapy (BRAF) the dice required by randomized studies forced us in the control arm of the study (chemotherapy, the SOC). If our cancer progresses, the study will allow us to switch to the new drug. However, if that fails, it means we are unable to access another study (ipilimumab) that has shown decent response results.

      Our oncologist believes that ipilimumab may soon be approved for use by the FDA – even so, there is no guarantee that our insurance company will help us, and we have no idea what treatments might cost us out-of-pocket. Enter “Compassionate Use.”

      Tell us more about such dispensing of new drugs. We assume there are probably grim preconditions associated with securing meds this way. We assume that Pharma is losing money on every dose they allocate for such use (and, as such, only distribute a small percentage of their production to these cases).

      To the novice, it seems like this is a path for Big Pharma to enter and show their compassionate side: to lower the cost of dispensing medicine when it isn’t accepted as the SOC and yet could be dispensed to a greater field of patients if their physicians feel that it may hold promise for them (which assumes, of course, that the docs have had a chance to digest appropriate CER before such decisions are made).