May 14 2009, 9:22AM
If "Evidence Based Medicine" is like "Sex Based Intercourse" then "Comparative Effectiveness Medicine" is like . . .?
President Obama is in a bit of a bind, lets face it with his laudable goal to have health coverage for all uninsured Americans. The health care math is simple: we already spend a ton on health care and his goal will require spending more. His options are to generate new revenue, or the other option (the needed option, I would say) is to cut costs. But you saw what happened to Hilary years ago when she tried that. To quote from a great series of articles in the Annals of Internal Medicine, "A dollar spent on medical care is a dollar of income for someone." Cutting costs means cutting income for lots of different players and they won't be happy, and yet there seems to be no other way.
But President Obama thinks he can raise money largely through three methods that no one has proven can save money:
1) Investing in Information Technology: I don't see how that saves money but it does ensure that America's doctors will get better tans on their faces from long exposure to screen glow; the iPatient in the computer will get great care while the patient in the bed will wonder where the doctors are.
2) Preventive medicine: Studies actually suggest this usually costs more money, despite all the theories of how it should save money
3) And finally the President wants to invest in "Comparative Effectiveness" research so that we only pay for what works.
What helped create our present mess is a payment system that rewards procedures and expensive diagnostic testing, but does not reward primary care; it has necessarily resulted in a profusion of people and places who do things that are well reimbursed and a dearth of physicians doing primary care. We don't need comparative effectiveness research as much as we need a retooling of the payment system and some caps on spending. Let's pay for what works right now, and stop paying for what's not needed.
I worry that "Comparative Effectiveness" or "CE" is going to be the next medical buzz word, just like "Evidence Based Medicine" or "EBM" has been the buzz word for a decade. "Evidence Based Medicine" is a term which makes about as much sense as "Sex-based intercourse"--Were we practicing based on zodiac signs before EBM came along? (By the way, I borrowed "sex based intercourse" after hearing a prominent chair of medicine say it--I don't know if he coined it, but I thought it was brilliant). Soon we'll have a generation of physicians who are CE experts to bump out the EBM experts.
Lets take away the incentives to do to patient and instead create incentives to do for patients, to be with patients. We don't need to do comparative effectiveness trials to see if that works; we can just ask patients.
Comments (11)
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Abraham Verghese
Brilliant post, Abraham. It's high time that we realize that replacing one purely analytical approach to medicine with another will lead to the same unfortunate outcomes. Comparative effectiveness is just as likely to lead insurers and practicioners alike to skip procedures that could have life-saving effects in order to save money as evidence-based medicine and other such bean-counter approaches. It's also just as likely to order needless tests that drive up expenses.
Your reframing of "doing to patients" to "for and with" them is just where we need to go. Our current payment system is so divorced from the reality of how good doctoring actually happens. Like so many other fields, all attempts at automation have achieved is a decision-making system that doesn't match up to the real world. Giving incentive to build closer connections and greater empathy between practicioners and patients is just what we need to save the field.
Keep up the great work!
Pete Mortensen
Co-author,
"Wired to Care: How Companies Prosper When They Create Widespread Empathy."
Excellent article -- I quite liked the 'Sex-based Research' remark (it certainly made me laugh!)
Although I certainly agree with most of the points mentioned in the article, I was quite curious about your second point (i.e. preventive medicine does not save money). I've always been a strong believer in the value of public health, and have previously believed that prevention measures such as vaccination, breast cancer screening, and cervical cancer screening were cost-effective.
I do understand that certain prevention programs are neither effective nor beneficial (i.e. abstinence-based sex education), but I believe that there are robust mechanisms that ensure that these programs are culled in favor of truly cost-effective measures.
I'd love to see citations for studies that state that preventive medicine is not cost-effective.
Thank you for your comments and Peter for the encouragement.
Dmaduram writes
"I've always been a strong believer in the value of public health, and have previously believed that prevention measures such as vaccination, breast cancer screening, and cervical cancer screening were cost-effective. I do understand that certain prevention programs are neither effective nor beneficial (i.e. abstinence-based sex education), but I believe that there are robust mechanisms that ensure that these programs are culled in favor of truly cost-effective measures"
If you click on the link in my piece in the fifth line under the word articles, you will come to the Annals editorial; then look in the references to the paper by Marmor, Oberlander and White who in turn quote the health economist Louise Russell who says "over the past 4 decades hundreds of studies have shown that prevention usually adds to medical spending." They go on to say that preventive measure that involve screening and regular doctor visits, rather than behavioural changes (diet and stopping smoking) are costly. I think good publich health measures such as sanitation, food safety probably are cost effective, but regular doctor visits are good for the patient but will probably generate more tests, more new diagnosis and more treatment.
Dear Mr. Varghese,
It appears that as yet, there have been no physicians responding to your editorial who can shed light on the nature of American medical care. Unfortunately, many of your comments are drawn from ignorance. I will explain why many of the President's initiatives make much sense to me, and should make sense to most thinking physicians.
1) Investing in information technology can save money in many ways, such as limiting the amount of paper, and reducing the bureaucratic minutiae of refaxing, remailing, and worst of all, reordering the same tests over and over because one does not have immediately have access to old ones. I have worked under conditions of no EMR and pervasive EMR and can tell you that my efficiency has increased exponentially. If EMR can have such an effect on one doctor, I can only imagine the difference for all. The lack of EMR investment in the US is also embarrassing, as one recent article indicated that only about 5% of medical services in the US use it as opposed to nearly 100% in most nations of the EU.
2) Regarding Preventing Medicine, I would like to see articles that point out how avoiding anti-hypertensive medications results in fewer strokes, or how not using insulin to treat diabetes prolongs life. Perhaps it may be true that avoiding preventative care is cheap, in the sense that those patients simply die early and thus avoid spending any money on medical care. On the contrary, articles on preventive measures are published all the time, and they are not just theoretical. (I just read one only 10 minutes ago!) Your comment on preventative care also contradicts your support of primary care. What do you think primary care physicians are doing most of the time? They are practicing preventative measures on patients who appear to be healthy, so that they don't have to treat them for debilitating and disabling complications later, which will cost much more.
3) I can agree with you that the reimbursement system is dysfunctional in this manner, and it will need to be changed.
Unfortunately, "evidence based medicine" is not a buzzword but a factual explanation of what medicine has only recently become. "Were we practicing based on zodiac signs before EBM came along?" Unfortunately, the answer is mostly "yes." Until about 30 years ago, most of medical practice was based on a series of anecdotal reports, traditions, opinions from authorities, case series, and about 1% based on actual empirical evidence. As more and more clinical trials have been performed, many of the tenets previously thought immutable have been rejected, and others have appeared that were quite unexpected. This has given rise to the saying that 50% of what a doctors learns in medical school is obsolete in 50 years. Some doctors still practice medicine that is not evidence based, and yet are being reimbursed for those practices in the current system. This also needs to change.
Sincerely,
A Concerned Physician
I would like to second what A Concerned Physician says above. During the first lecture I attended in medical school, the professor said, "Half of everything you are about to learn is wrong, We don't know which half it is, so you have to learn it all. You must also continue to question and learn."
During my career, many areas of medical certainty have been turned on their heads, all through the use of randomized controlled trials. RCT's are the heart of EBM, and save lives(as well as money) on many fronts. When I was in medical school, it was dogma that hormone replacement therapy for women saved lives by preventing heart attacks, and might even prevent Alzheimer's Disease. In fact, both theories were proven resoundingly wrong when well done, adequately powered RCT's were released. If I didn't practice EBM, I would have continued to prescribe HRT, and my patients would have had a higher risk of death from heart disease, breast cancer, as well as a potential higher risk of Alzheimer's Disease, as well.
The opponents of EBM are, generally speaking, more procedure based physicians. In America, physicians who perform procedures are paid vast sums of money, whereas cognitive based physicians (read Primary Care), are paid relatively poorly. The disparity greatly favors the procedure based physicians, and they are loath to have their livelihoods placed under the microscope of EBM.
Any medical practice that saves lives and saves money is money well spent. A practice that either kills patients or has the same outcome at a higher price than alternative treatments should be abandoned. The only way to determine if a medical practice makes sense is through EBM.
I'm afraid from my perspective, "evidence based medicine" is not so obvious. Quite aside from the lack of evidence the doctor above pointed out, the people I know socially are quite uninterested in evidence based medicine, and I see this on the net very strongly, too. Here in Washington, we have a (horrendous) law that requires insurance companies to reimburse for every kind of medical provider- so insurance companies are reimbursing for chiropracters, osteopaths, naturopaths, herbalists, homeopaths, and acupuncturists. Within hospital-based medicine, evidence has always at least been valued, if not used; out in the world of patients, "evidence-based medicine" is often decried as the horrible conventional medical approach.
It makes me angry to see my tax money and insurance premiums going to quacks. I don't know anything about the politics of "evidence-based medicine" within the community of doctors who went to medical school, but I certainly want any national health plan to only support evidence-based medicine. It may seem obvious to you, but it needs to be specified, just as funding for health and sex education for teenagers needs to exclude abstinence-only programs.
Good IT is very useful for tracking medications. I usually live in Australia and tracking prescriptions is helping to reduce overuse of medication.
We also have a wonderful public health care system. Yes, socialize medicine and the world didn't end.
Now I am living in a 3rd world country and preventative medicine can get very basic indeed - like using/having access to a toilet and clean water.
Perhaps you can expand on what kind of preventative medicine you mean.
gardensnail
Dr. Verghese is correct on multiple issues. Neither health IT nor preventive medicine will cost costs in our current medical system. For health IT to function properly and lower administrative concerns, all of the systems would have to be 100% compatible with each other, something that is unlikely given the current disarray in the heatlhcare IT sector. It's important to realize that without a standard system, every time a program becomes obsolete it has to be replaced (e.g. imagine a lot of non-compatible, expensive systems being redesigned every ten years).
Preventive care also runs into strange problems. Prolonging life may not always work to a cost cutting advantage when payments are so skewed towards procedural care. Since most spending occurs in the last months of life, older individuals will inevitably develop more complex and chronic conditions that are difficult to treat effectively. Unfortunately, this can mean that instead of paying now for acute problems that develop from conditions like untreated diabetes, we will delay costs until later.
Neither these two options, nor comparative effectiveness research, will make much of a difference unless the serious cost issues like drug costs, procedural incentives, and other pervasive issues are addressed.
Dear Dr. Verghese, could you please list a few example studies describing the higher cost of preventive medicine? I don't doubt what you're saying. We get such little info on preventive medicine in school that we just take for granted that it would save money downstream.
Thanks,
David
4th year medical student
Hi,
I'm a reader from the UK. This was an interesting article and makes a few very valid cautionary points about the new administration's policy. In response to david (above) I'd suggest checking out the Louise Russell paper mentioned. Its available toe free at:
http://www.nchc.org/documents/nchc_report.pdf
In response to some of the other contributors preventive medicine may do all sorts of wonderful things but reducing costs is often not one of them. The experience in the UK has been interesting. The founders of the UK national health service (in the 1940s) originally envisaged that costs would go down after a few years of tackling the big health problems of the day. Reminding people of this now raises a hollow laugh as the costs increase every year keeping pace with both improving treatments and peoples' expectations. Its a cautionary tale. The UK NHS is an incredible system but it does cost and the costs always increase (though perhaps they always should).
Investing in IT is also a risky strategy. I've been working in the UK NHS over the last 12 years while developing integrated electronic patient records have been a priority. When this works it too is great but getting there has involved a staggering investment of money and staff time. Again, it may be a desirable thing to do but its not a cost saver (at least in the next few years).
Only paying for wwhat works sounds eminently sensible. We've gone for this in a big way in the UK via the National Institute for Clinical Excellence which issues treatment guidelines. Whey they are just guidelines they can be helpful. However when they become too proscriptive they are problematic. For example recently we've invested in a policy to get people with long term mental health problems off incapacity benefit. You'd imagine that this would involved a range of medical, psychological, social and economic interventions. Instead we've spent 173 million UK pounds on Cognitive Behaviour Therapy and ignored other treatments because that one is percieved as the "Best". So we've ended up with a very simplistic policy where they range od people's need is reduced to one-size-fits-all. Its incredibly important with these kind of guidelines to both allow room for clinical judgement and not to stifle innovation (another risk of deciding one thing is the best and others are not worth investing in).
I think you're in for some fun over there. I really hope you get there as your current system seems a little crazy from a European perspective. Incidentally Paul Krugman has some interesting things to say about how the current US set up contains incentives to push up costs through the mixed (private and state) nature of the care. For example I gather it is often the case that some kind of preventive treatments are less likely to be given to (for example) a man in his 50s because the government will pick it up in 10 years. Does this kind of thing really go on?
Dear Abe: Your commentary is right on target. One point, however, that is often overlooked in the preventive medicine debate is that the tax base will increase if preventive medicine "prevents" disability. How much the tax base will increase is open to conjecture. Your are right on when you say preventive medicine costs more in the end, but if the population is healthier and keeps working, it might be worth the extra money spent in the end. The 800 pound gorilla in the living room that very few are discussing (viz. recent NEJM editorials on health care reform) is defensive medicine and how to rein that in. In our ER, I guesstimate that more than half the imaging studies ordered were done defensively and were really not indicated. I am quite pleased with the openness of the debate on healthcare fostered by the Obama administration. Hopefully, with all the input from all sides of the healthcare system, the result will be a more equitable and more efficient American system. Regards, Joseph Alpert