One of the subplots behind the negotiations over the just passed stimulus bill is that, as Steven Pearlstein points outin the Huffington Post, the drug and medical equipment manufacturers joined forces with the disease advocacy groups ("like Easter Seals and the American Cancer Society") to attempt to gut the stimulus bill's money for research on the comparative effectiveness of treatments. Those groups don't want us to know whether some expensive treatments are worse or no better than cheaper treatments. They united to attempt to remove money for "comparative effectiveness research" from the stimulus package, and almost succeeded.
This unholy trinity want to replace money for "comparative effectiveness research" with support for "clinical effectiveness research." That single word difference would have profound effects, to the benefit of the companies and the detriment of the rest of us. "Clinical effectiveness research" merely determines if a treatment is better than doing nothing, without determining if it is better than alternative treatments. In their desired model of research, a new drug is compared to a placebo sugar pill. If it works better than the sugar pill, the drug company can launch a full campaign to get doctors to prescribe, and us to take, their newest drugs that, because they are still under patent, may cost many times more than the cheaper generic. The last thing the drug companies want us to know is if their new patented pill is any better, or even as effective as, the far cheaper generic. The medical equipment manufacturers similarly want doctors to use their latest inventions without any evidence that they are better than the last generation of medical devices.
While one can't help wondering about the influence of manufacturer money, the interests of the disease advocacy groups are apparently at least in part more benign, though equally dangerous. As Pearlstein explains:
The flames were also fanned by "disease groups" like Easter Seals and the American Cancer Society, which fear that any attempt to determine what works best will inevitably lead to a one-size-fits-all approach to treating people with serious chronic conditions.
Maintaining clinical flexibility is important. But it cannot and should not come at the expense of understanding what works best and what doesn't work as well. Only comparative research can answer these questions. The advocacy groups are doing the public a disservice by joining the drug and equipment manufacturers in their effort to stifle comparative research.
Pearlstein points out that the report of the House Committee on Appropriations explained the rationale for this research in clear language:
"By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those [treatments] that are most effective . . . will be utilized, while those that are found to be less effective and in some cases more expensive will no longer be prescribed."
As with everything, there are dangers in comparative effectiveness research. Sometimes outcomes measures are tailored to produce desired results. The research can then be misused as a rationale for refusing treatments solely because they are expensive. But that is a misuse.
As the costs of medical treatment rise ever higher, some type of cost controls are inevitable. It is simply not possible for healthcare costs to continue rising at the present rate. Either such cost controls will be based upon the best available research or they will be based upon far less desirable criterion. It is in the interests of everyone other than those peddling expensive ineffective treatments for us to develop a rational, comprehensive, and sophisticated system for conducting high quality comparative effectiveness research.
While this may seem like an arcane issue, only if we use our health resources wisely to fund effective, and cost-effective treatments, do we have any hope of getting health care costs under control. Every dollar spent on an ineffective treatment is a dollar that could go to providing health care for all, or for meeting any of the numerous other unmet social needs. Without control of health costs, universal coverage will never arrive, it will always be defeated as too expensive. In fact, a health costs rise, increasingly we will find ourselves denied even effective treatments by irrational and ineffective ways of controlling costs.
Of course, the drug and medical equipment companies have no interest in getting health care costs under control. The more we spend, the more profit they earn. Whether that money leads to improved health is none of their concern. But it should be of primary concern for the rest of us.
It is sad that the disease advocacy groups went along with this farce. We don't need only to spend more on the fight against cancer. We need to spend more wisely on cancer. Expensive treatments, costing tens or hundreds of thousands of dollars should only be paid for out of public funds if they work better than cheaper alternatives. "Comparative effectiveness research" would seem like a no-brainer, but it almost got defeated by this unholy coalition. These same folks will unite again to fight every improvement to our healthcare system. We cannot afford to let them win.
[Also posted on Psyche, Science, and Society.]