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Whether vs. where

Speaking of Paul Ryan, I wanted to say a few words on a part of our interview that didn't attract much notice. Namely, this exchange:

When you talk about making people more powerful, that brings up some questions about the employer market. In theory, the employer market is big enough to have this effect. It’s big enough to work like a real market. But we both agree it’s not a real market, and even more, that you should end the exclusion. Where we part is on the question of who has the power. I’d say consumers don’t have the power. You’ll give consumers buying power. But I’d look at decisions power. And the real power there lies with doctors. I don’t do anything without a doctor telling me to do it. How does this change the doctor’s behavior?

What I also have in this bill is the health-care services commission. It is a system whereby all these stakeholders in health care – providers, doctors, insurers, consumer groups, hospitals, unions – all come up with standard metrics that are standardized that we hold for price and quality and best practices. It’s a lot different than a comparative effectiveness approach. This way, the consumer sees who’s good and who’s bad. I think we need to make a big reach towards transparency.

To make this a bit clearer, comparative effectiveness review is where the government spends a lot of money commissioning research into the relative effectiveness of different treatments. That way, when your doctor is deciding whether to prescribe surgery or physical therapy for your back, he has plenty of evidence with which to make his decision. To a degree that people don't really appreciate, medicine has way too little information today.

What Ryan is talking about is a way to evaluate hospitals against one another. His vision would make it easy to compare prices, practices, success rates and so forth. In the next paragraph of the interview, he makes the point more sharply by talking about price variations among different hospitals in Milwaukee.

These two things are not exclusive, and they're not even particularly related. Comparative effectiveness is about whether to do something. The price/outcome measures Ryan is talking about relate to where you get something done. Ideally, we should have both. It's good to know whether you should have back surgery and good to know where you should get it done.

But conservatives have real problems with the comparative effectiveness approach, as they believe that that will eventually lead to government dictating which treatments you can and can't purchase. I don't think that's very likely, but I'd support government using good evidence to decide which treatments it will reimburse at 100% and which it will reimburse at 30% in the programs that taxpayers are on the hook for. Paying for everything based on a hunch and a study funded by the device manufacturer doesn't make a lot of sense.

By Ezra Klein  |  February 5, 2010; 2:52 PM ET
Categories:  Health Economics  
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Next: Money in politics, cont'd.

Comments

How is this performance review even a conservative idea? It's a completely non-ideological concept. Except, of course, that you would need the government to do it. And if the government does it, conservatives are against it. Of course, if doing nothing were a solution to a problem, it would not be a problem. Hence the sterility of modern conservatism.

I know the idea here is to engage in bonafide "conservative" ideas to take advantage of the limited sanity to foster good-faith efforts at dialogue. But, really, it seems so academic. We're never going to get anywhere with conservatives until they grow up past their free-market absolutism, government paranoia, and political blood lust.

Sorry for the rant. I'm feeling a bit partisan this week.

Posted by: inkadu | February 5, 2010 3:05 PM | Report abuse

If I can use the government's 30% and enhance that with my own money or private piggyback insurance if I so choose, count me in. If it's the government's 30% or nothing, fooey on that.

Posted by: bgmma50 | February 5, 2010 3:10 PM | Report abuse

This is totally off-topic, but are you ever bothered by your gendered pronouns? I know you are technically right, but it still feels off. Especially because I was just having this discussion with my girlfriend, who is off at med school. While I stay home and write my dissertation on animal ethics.

Posted by: thescuspeaks | February 5, 2010 3:25 PM | Report abuse

Cf. the mantra of the British Health Service: "We cover everyone. We don't cover everything." I love that - though there are way better health care services than the Brits'.

Posted by: sprung4 | February 5, 2010 3:25 PM | Report abuse

I think government-sponsored comparative effectiveness research and treatment guidelines derived therefrom makes a lot of sense. And I see no reason why the government should pay for treatments which have have not been demonstrated to be efficacious. But doctors should still be free to recommend non-approved treatements and patients to pay for them, if that is their wish. In practice I think a lot of private insurers would follow the governemnt's lead, crafting a benefit schedule that only covered approved treatements.

Comparative pricing and outcomes information is a no-brainer.

Posted by: tbass1 | February 5, 2010 3:28 PM | Report abuse

If the government uses comparative effective conclusions to decide which procedures to cover and which to decline, what does this mean for the comparative effective questions for everything else the government chooses to fund?

I think you are overlooking the massive hole in use by the government of comparative effectiveness. If used in one budget item, why wouldn't they be extended to other budget items?

Good bye Head Start. So long American for Disabilties Act subsidies. Public transit funding?

The Pentagon already uses a similar approach, but like anything the government does, you can always buy your way to shift eyes to what you want them to see.

Posted by: snannerb | February 5, 2010 3:44 PM | Report abuse

When offer Grandma a pain pill because the expensive procedure only has a 15% chance of saving her life, that's "comparative effectiveness." Because it would be a shame to "waste" that expensive care on a long shot.

Posted by: whoisjohngaltcom | February 5, 2010 4:41 PM | Report abuse

"comparative effectiveness" ... drug company sponsored, academic medical institution sponsored or government sponsored is what we in clinical medicine actually do! This is what our whole profession does.

All doctors in the modern (since 1960) era have entered the field committing to be life-long learners. There was actually a time when one human being could actually master all of the field of medicine. That time has long since past and therefore sub-specialization has become an absolute necessity for providing expert medical advice and treatment. Those posting here act as if it is a novel concept. Further deluding the readership of the actual issue... how do we become a more perfect union of citizens with regard to caring for the sick and dying?

I personally favor: the public option, required insurance bought on an open exchange, anti-trust enforcement in the health insurance industry, and responsible tort reform including the formation of expert juries.

Posted by: DOC_J | February 5, 2010 4:43 PM | Report abuse

Ezra,

Considering a majority of conservatives think of creationism in the same scientific ballpark as the theory of evolution, I have no doubt they'll see no middle ground when it comes to comparative effectiveness. To them, it's all about belief, so you leave it up to consumers who are first making a leap of faith that their doctor understands the comparitive effectiveness of the procedures they're prescribing.

Posted by: Jaycal | February 5, 2010 5:03 PM | Report abuse

"comparative effectiveness"... is what our whole profession does.

To some degree, certainly. But as I understand it, what typically happens when a drug company develops a new drug is that it runs the federally mandated tests to verify that the drug is relatively safe and is more effective than a placebo. It then launches a marketing campaign to convince doctors to prescribe it, rather than other drugs that treat the same condition.

I have heard of cases where drug companies tested their products against competing treatments, or where such comparisions have been done by researchers getting funding from other sources. Unless I'm badly misinformed, this isn't the norm.

Posted by: KennethAlmquist | February 5, 2010 6:43 PM | Report abuse

"When offer Grandma a pain pill because the expensive procedure only has a 15% 15% chance of saving her life, that's "comparative effectiveness."


I'm worried that the writer of this non-sequitur has been taking too much of Grandma's pain medication this evening.

Posted by: Patrick_M | February 5, 2010 7:41 PM | Report abuse

"Unless I'm badly misinformed, this isn't the norm."

It is the norm. Europe requires comparative trials of every drug that is in a disease with existing therapeutic options. Drug development is global, as are the trials, and resulting data. The comparisons may not be the "ideal one"-- drug company compared A vs B when docs may be more interested in B vs C. But even this is ignoring that while technically data from separate trials can't be compared, it happens all of the time in medicine. So A vs placebo in one trial, and B vs placebo in a second trial. Doctors do the indirect A vs B comparison routinely. The basic trial characteristics and data collected are very similar.

Posted by: wisewon | February 5, 2010 8:12 PM | Report abuse

"they believe that that will eventually lead to government dictating which treatments you can and can't purchase. I don't think that's very likely, but I'd support government using good evidence to decide which treatments it will reimburse at 100% and which it will reimburse at 30% in the programs that taxpayers are on the hook for."

Distinction without a difference.

Managed care over the past 15 years has several great examples showing that while people strenuously object to wholesale restrictions, they are more accepting of financial incentives influencing their behavior-- to almost the same effect. And those examples aren't close to the 30% vs. 100% differential in your example. A $50 co-pay does wonders for driving drug formulary compliance, a 10 or 20% cost share does wonders on the provider side. So if that's what you believe as stated above, you pretty much agree with Republican criticisms. And you're all right. There's no question that this is the intent. As it should be. I've just said in the past, and as described in the past comment, why less data needs to be collected, versus making value-based purchasing on a fair amount of existing data today. We're again just avoiding the heavy political lifting, hoping the data will provide crystal clear answers. It won't, for a variety of reasons that will always be too technical for the media or politicians to understand. So let's start making the tough calls on the data we've got and we can supplement with more research. But even that research is more focused on generating primary clinical effectiveness data, not comparisons to alternative treatment options.

Posted by: wisewon | February 5, 2010 8:22 PM | Report abuse

An old comment further explaining my point on comparative effectiveness review (CER):

Let me give two analogies to try and make this more clear.

1. Imagine Ezra is sitting down with his editors figuring out he can increase his readership. They pull out two pieces of data: the first shows that people aged 25-40 who use the internet 10+ hours per week are 20% more likely to visit a blog that has pictures embedded in the posts. The other piece of data shows that males aged 22-30 who use the internet 15+ hours per week are 50% more likely to visit a blog that has Youtube videos embedded in the posts. So should Ezra add more pictures or video? Now, Ezra and his editors could sit down and say, yeah the study population is a little different between the two studies, but its pretty reasonable to assume that even if the broader population range (both ages and sex) were tested on Youtube impact, it would still be higher than 20% seen with pictures. This is what the CER concept thinks isn't good enough-- i.e. we need the definitive study comparing embedded pictures and videos directly in the same people so we definitely know which is better. Yeah, you could do it, but the impact is only marginally better. Using the existing data today is going to be correct a lot of the time. This is what NICE is doing today.

2. The second analogy relates to physicians practicing on their own. So pretend that only the Youtube data exists. Ezra is looking to grow his readership-- the editors think he could get more readers in the 50+ category. Ezra says, well, the Youtube data shows that readership increases (ignoring the age/sex demographic) so he adds more Youtube to get more 50+ readers at this site. A comparative effectiveness study would look at "are picture or youtube videos better in gaining readership among people 50+?" I'm saying that let's make this a little more simple-- how about any data that shows that Youtube is effective in the 50+ population at all? The comparative study is more complicated (and expensive), so let's start with just getting some basic effectivenss data to support Ezra's Youtube decision.

Posted by: wisewon | February 5, 2010 8:26 PM | Report abuse

Sounds okay to me - you should try the less expensive treatment before you go to the more expensive one, especially if the less expensive one is on average as effective.

Having said that, when you're dealing with meds, different people react in different ways. As an example, my partner has MS and the consequent severe periodic muscle spasms in his legs. Imagine the worst charley horse you've had, multiplied by ten, several times a day. The standard treatment is Clonazepam. Our insurance doesn't even have to pay for it, because a month's supply is about $6.50 (less than the copay for generics). However, enough Clonazepam to control the spasms would leave him asleep virtually the whole day (just the way his body chemistry works, I suppose). He also has been prescribed Mirapex, which helps to control the spasms without the narcolepsy. A month's supply is almost $260, and our copay (as a non-formulary med) is $50. We can swing $600 a year, and something north of $3,000 would pinch but would be doable, but what if the med were $1,000 per month? Would the government just say, "Hey, it works on average without too many side effects. Sorry you're not average. Enjoy your nap."

Just saying that, as with so many other things, the details are everything.

Posted by: donkensler | February 5, 2010 8:31 PM | Report abuse

It's naive to believe that CER will do anything to institutionalize best practices as long as the drug/surgery model of medicine continues supreme - which it will for ideological, political, and psychological reasons.

One example of literally dozens:

There are loads of high quality studies (most from Germany and other parts of Europe) that show that st johns wart is equally if not more effective for mild to moderate depression than patent medicines. Yet I doubt that even 1% of doctors choose it, despite being vastly less expensive and much safer. And no insurance company reimburses for it despite its proven CE.

Does anyone believe that Pharma, the medical schools, the NIH and the AMA would allow the entity in charge of CER to be comprised of scientists and practitioners sympathetic (or even open minded) to an herb. Of course not.

So unless the power and ideological roots of our system are reformed we're simply further institutionalizing a corrupt system that kills people while simultaneously bankrupting the country.

Neat system isn't it?

Maybe once in the hundreds of posts on health care Ezra will address the world of natural health and its utter marginalization and demonization by the media, PHarma and most everyone else who makes a buck out of sickness.

Posted by: oderb | February 6, 2010 3:32 AM | Report abuse

Ryan misses the point. The whether to do something is more important than the where (though that is important too)....but the reality is, if I am going to have a major operation I go where my doctor has admitting privileges. I do not care if it costs $30,000 or $25,000 or $20,000 as I have an out of pocket limit on my expense. After a day in the hospital, I am being reimbursed at 100% regardless of where I am.

Posted by: scott1959 | February 6, 2010 11:07 AM | Report abuse

one thing Mr Ryan and Zeke Emmanuel of the White House agree on is the use of vouchers as an economic mechanism for health insurance

i think vouchers in the hands of citizens free to chose their health insurer and free to choose their doctor and their hospital would bring needed price competition into health care services

at the moment, the insurers, the doctors,the hospitals and congress negotiate prices

and one thing about health care that just about everyone agrees with (maybe excluding pharma and device makers and some doctors) is it cost too much

most of the cost issue is a price problem

prices are higher than they ought to be

drugs, tests, procedures, physician fees

this is obvious from comparative data from europe

Posted by: jamesoneill | February 6, 2010 12:00 PM | Report abuse

"There are loads of high quality studies (most from Germany and other parts of Europe) that show that st johns wart is equally if not more effective for mild to moderate depression than patent medicines. Yet I doubt that even 1% of doctors choose it, despite being vastly less expensive and much safer. And no insurance company reimburses for it despite its proven CE."

There's loads of all sorts of medical information on the internet. I have often diagnosed minor medical issues and treated them homeopathically or discovered that a bit of time and patience heals a remarkable number of things with no need to run off to the doctor demanding a prescription.

Guess what. I have high deductible insurance coverage. If I some gold plating on it, I'd probably think nothing of waltzing into the doctor's office for every sneeze and rash.

Posted by: bgmma50 | February 6, 2010 12:15 PM | Report abuse

"If I some gold plating on it, I'd probably think nothing of waltzing into the doctor's office for every sneeze and rash."

Really? For me, the inherent upleasantness of visiting a doctor's office is itself sufficient reason to avoid unnecessary examinations, tests, and treatments. And everyone that I know feels exactly the same way.

I guess that a certain percentage of the population must consist of hypochondriacs and masochists who feel otherwise, but I am willing to bet that the vast majority of people visit the doctor only for routine periodic examinations and when there is a perfectly legitimate concern over unusual symptoms, even when they have low co-pays and deductibles.

And logic dictates that it is cheaper in the long run to have a system in place that tolerates a certain percentage of unnecessary visits, rather than creating disincentives for sick people to get their symptoms diagnosed sooner rather than later.

Posted by: Patrick_M | February 6, 2010 4:19 PM | Report abuse

"but I am willing to bet that the vast majority of people visit the doctor only for routine periodic examinations and when there is a perfectly legitimate concern over unusual symptoms, even when they have low co-pays and deductibles."

You mean you're willing to be somebody else's money that the vast etc. etc. etc.

"And logic dictates that it is cheaper in the long run to have a system in place that tolerates a certain percentage of unnecessary visits, rather than creating disincentives for sick people to get their symptoms diagnosed sooner rather than later"

You meant the same people like you and everybody you know who already know which examinations, tests, and treatments are unneccessary and are thus able to avoid the inherent unpleasantness of a doctor visit except for those that happen to be necessary?


Posted by: bgmma50 | February 6, 2010 6:20 PM | Report abuse

"You mean you're willing to be (sic) somebody else's money that the vast etc. etc. etc."

You have private health insurance. So that bet is made all the time using somebody else's money (and a little of your own) for the care you are getting now. Nothing changes if you are in a public or private pool, they all must operate on the "bet" that unnecessary services will be minimal. If you have data to show that a public-funded system like the VA is dispensing more uneccessary care than the private insurance system, please do share it. Otherwise, unless you pay for your care 100% out-of-pocket like the uninsured, every system (public or private) includes that "bet" and so every system must set policies about what services are needed.

And yes, I WOULD make the bet that most people don't go to see the doctor just because it is so much darn fun to be there, getting one's blood drawn, disrobing, etc. I also would bet that it will be cheaper in the long run to error on the side of a few unnecessary tests and treatments, rather than to create obstacles to needed early-stage care.

"You meant the same people like you and everybody you know who already know which examinations, tests, and treatments are unneccessary and are thus able to avoid the inherent unpleasantness of a doctor visit except for those that happen to be necessary?"

No, I meant that I only go in for recommended examinations and on those rare occasions when I become ill with something more serious than a routine virus. I then leave it to the doctor to determine what tests and treatments are necessary, in light of my symptoms. Seems like a sensible way to operate to me, I don't think my behavior has generated any needless expense to anyone. I will further bet that there are more sick people waiting than they should to see their doctor than there are healthy people who "waltz" in when nothing in particular is wrong with them.

In case my simple point remains unclear: what I meant was simply that (unlike you) I take no pleasure from medical appointments and so I know that (unlike you) I would not ever "think nothing of waltzing into the doctor's office for every sneeze and rash" if I had a policy with a low deductible, and I also don't think that very many people with low deductibles are doing that now, just because they enjoy wasteful consumption of medical resources that are paid for "with other people's money."

In summary:

1. If your health care was less expensive, you would go in for a sneeze or a rash, but in the same scenario, I would not.

2. Therefore I would not generate the unnecessary medical care that you would.

3. Of the two of us, I strongly doubt that my behavior would be the more unusual.

Posted by: Patrick_M | February 6, 2010 7:07 PM | Report abuse

"You mean you're willing to be (sic) somebody else's money that the vast etc. etc. etc"

I love it when somebody attacks my typos.

"Nothing changes if you are in a public or private pool, they all must operate on the "bet" that unnecessary services will be minimal."

If that was the case, I'd be far less concerned than I am. I regard the House bill in particular as an open invitation to consume unecessary services.

"If you have data to show that a public-funded system like the VA is dispensing more uneccessary care than the private insurance system, please do share it."

If you have data to show that the House and Senate bills propose to creat VA-style health care, please do share it.

Unless the public pool is explicitly

Posted by: bgmma50 | February 6, 2010 10:21 PM | Report abuse

"No, I meant that I only go in for recommended examinations and on those rare occasions when I become ill with something more serious than a routine virus. I then leave it to the doctor to determine what tests and treatments are necessary, in light of my symptoms."

Uh huh. So we are agreed that chest pains and organ lumps will send folks to the doctor, irregardless of whether or not they have to disrobe or pay money even if they have high deductibles and copays.

"In case my simple point remains unclear: what I meant was simply that (unlike you) I take no pleasure from medical appointments"

Umm, since the post that started this argument had me saying that I use the internet to diagnose health issues and utilize homeopathic remedies, your "restatement" is disingenous as best.

But there really are many, many people who thoroughy enjoy ill health, and just because your limited acquaintance doesn't include them doesn't mean they don't exist. And it certainly doesn't mean that I should be happy about allowing you to drag me kicking and screaming into supporting them

Posted by: bgmma50 | February 6, 2010 10:33 PM | Report abuse

"In summary:

1. If your health care was less expensive, you would go in for a sneeze or a rash, but in the same scenario, I would not."

Let me put it this way. I choose high deductible insurance because I believe in paying for my own basic health care needs and foregoing professional medical care when I have figured out that a day in bed and some fluids is all I need.

HOWEVER, if I am dragged kicking and screaming into a health care system that extracts more money from me than I cost, and counts on my good health habits and frugal nature to subidize those who don't have a similar regard for their health and pocketbooks, I've got news for you. I will get my money's worth. Waltzing into the doctor's office for every sniffle, sneeze and rash is only the beginning.

Posted by: bgmma50 | February 6, 2010 11:05 PM | Report abuse

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