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Posted at 9:07 AM ET, 03/11/2011

Why does Mike Huckabee want Medicare to waste money?

By Ezra Klein

What is comparative-effectiveness review? There are two answers to this question. The right answer, and Mike Huckabee’s answer.

The right answer is that comparative-effectiveness review is a fancy term for studies that test multiple drugs or treatments against one another to see which one works best — studies, in other words, that compare them for effectiveness. That way, when doctors go to prescribe something for you, they’re prescribing the thing that’ll do the most to help you at the lowest cost. My hunch is that most patients think comparative-effectiveness review is already how medicine works, and would be dismayed to learn how little good evidence there is behind what their doctor is telling them.

Mike Huckabee’s answer is that comparative-effectiveness review is the seed from which “the poisonous tree of death panels will grow,” which is, if not a sensical image, at least a vivid one. CER will become our version of Britain’s National Institute for Health and Clinical Excellence, which in Huckabee’s telling, “decides who lives and who dies based on age and cost of treatment.”

You’ll notice that nowhere in Huckabee’s description of comparative-effectiveness review is the “comparing for effectiveness” part mentioned. Instead, Huckabee is engaged in an effort to take evidence-based evaluation of different treatments off the table. And Huckabee isn’t alone in this effort. In January of 2009, Mitch McConnell, Jon Kyl, and Pat Roberts cosponsored legislation banning Medicare from using comparative-effectiveness review data to make coverage decisions. If I’m remembering this correctly, the GOP managed to get language along these lines into the stimulus.

So at the moment, the Republican Party’s position is that Medicare and Medicaid cannot use studies measuring the effectiveness of different medical treatments when deciding what to cover or not cover. Another way to say that is they’ve decided against saving money by making better decisions about what to buy. Their remaining options are to save money by paying doctors and hospitals less than things currently cost, or to save money by giving seniors and Medicaid recipients less than they currently need. With smart rationing off the table, dumb rationing is all we have left.

By Ezra Klein  | March 11, 2011; 9:07 AM ET
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Does Huckabee's position imply that Medicare is obliged to pay for copper bracelets for arthritis? Does Medicare have to finance prayer circles to pray for the sick? How about trips to Lourdes?

Posted by: reifier | March 11, 2011 9:33 AM | Report abuse

Don't miss the elephant in the room. There are millions of investment dollars at stake.

If the effectiveness (not under corporate control) does not pan out, these investments are lost.

Thus, many companies prefer the current system of NOT collecting data and using their marketing (under corporate control) to drive adoption.

The politicians owe allegiance to BigPharma and BigMed, not to little consumers.

Posted by: bakho | March 11, 2011 9:49 AM | Report abuse

Medicare should select drugs based on which drug company gives politicians the most money. Obviously the company with the most money is the best company!

Posted by: DavidCEisen | March 11, 2011 10:04 AM | Report abuse

While Huckabee is clearly engaged in nonsense, isn't there a germ of truth in the following concern: CER shows treatment A to be superior to treatment B in 95% of cases, but my provider reasonably believes I happen to fall into the 5%?

Posted by: jduptonma | March 11, 2011 10:07 AM | Report abuse

One problem with comparative effectiveness is that, in a market, costs aren't fixed. If a treatment isn't worth a QALY cutoff value at one price, it may be at a lower price. One reason comparative effectiveness logic doesn't make it through to lunkheads like Huckabee is that he probably pays a $25 copay for a prescription, whether the drug costs $300 or $3000. With comparative effectiveness in this weird consumer fixed-price environment, you are telling Huckabee that he's allowed to get one thing for $25, and one he's not allowed to get at all. Maybe a better model is to use a reference price- cover the $300 and let him pay the $2700 if he really wants that other drug.

Of course, with medical procedures, the incentives are even more blown up than they are with drugs, because the doctor directly benefits. There is no incentive in the system for people to choose low cost care or for providers to provide it.

John Goodman's recent post showed how the ACA is actually going to make this even worse by systemizing the choices made by these sort of government run analysis teams. Gawande's article on Dr. Benner is a great example of how people aren't seeing the unintended consequences of having a government panel drive treatment decisions, and how it will drive out disruptive innovations by picking winners.

Why don't we have government panels tell us which car to buy, or where is the most cost effective place to live, go to university, etc.? Surely there is a most cost effective choice for each person? Instead, some people choose to spend a lot more, some a lot less, some buy for status reasons... Market prices are amazing things, containing latent information from a huge combination of preferences and supply information. Distorting that signal is so difficult.

So, comparative effectiveness studies are useful, and helpful in determining how to fairly spend other people's money. However, most of us would prefer to be given the information and make the decisions ourselves, by having control over our own budgets and feeling the impacts of the decisions we make on what services to buy.

Posted by: staticvars | March 11, 2011 10:16 AM | Report abuse

"but my provider reasonably believes I happen to fall into the 5%?"

That's clearly what fuels opposition to CER. It seems to be human nature to worry that we'll be the worst case scenario and believe that I will be the one-in-a-million person who will not obtain a "cutting edge," magical treatment, rather than among the 999,999 people who will get more effective treatments.

As to jduptonma's specific point, I don't know the details, but with most insurers, there is an appeal process for denial of coverage, and if the doctor has a real basis to believe that you're in the 5% group, you can apply to have that covered. If that fails, then the patient can pay out of pocket if she feels that her doctor's judgment is sound.

Posted by: JEinATL | March 11, 2011 10:20 AM | Report abuse

why does Mike Huckabee wnat medicare to waste money?

uh, because he's pandering to his base that doesn't understand it.

and to further JEinATL's point not only does most every insurer have those processes in place most every state (at least the liberal ones) also have state departments of insurance that you can file complaints to if you feel somethings not being covered that should be and in the end in the current anti-insurer enviorment many times insurers will (incorrectly) adjust what they do to avoid something going to the DOI.

Posted by: visionbrkr | March 11, 2011 10:33 AM | Report abuse

You're missing the point.

Any treatment that loses a comparative effectiveness review is a business that loses access to the stream of taxpayer money.

You don't really have to look much further than that.

Posted by: pj_camp | March 11, 2011 10:35 AM | Report abuse

staticvars, that's an interesting idea that I'd like to see teased out by Ezra or someone else: Use CER to determine the most effective treatments and then set reimbursment rates at the cost of that treatment. If a doctor wants to use a drug that's less effective (but not completely bogus medicine) but costs half as much, that's ok. If the doctor wants to use drug that's less effective but costs twice as much, Medicare pays the cost of the most effective treatment and the patient can make up the difference if they really think that's best or they can appeal the decision and make the case that this is one of the minority of cases where this particular treatment might be more effective and should therefore be covered.

As for your cars analogy, it breaks down in that we're talking about people participating in Medicare and Medicaid, which are government programs. There's no government car buying agency that's expected to shell out money for someone buying some junker that will fall apart when there's a more reliable model for the same price or less.

Re: Huckabee, this is one of a million instances where conservatives oppose have a tiny grain of legitimate fear, but rather than working with liberals to shape the system into something that will allay their fears, they paint the entire idea as evil. If conservatives are worried that some small percentage of people will find themselves on the wrong side of statistical averages and be denied coverage, there are ways we can build in protections for those extreme examples. That fear doesn't mean we should ignore CER altogether, but then, we all know this is just Huckabee being conveniently dumb for politics' sake.

Posted by: MosBen | March 11, 2011 11:03 AM | Report abuse

Aarrgh...the problem is that so many comparative studies are done by drug companies. They hide unfavorable data. Then you find that treatment A is better than B, and B is better than C, and C is better than A. (All from different drug companies of course.) Or that the patient also has X, Y, and Z conditions, which these studies excluded from their data. True story: my illness only, and I mean only, got better when I stopped doing everything that doctors told me to do, and I mean everything. My "result" will never appear in one of those studies. They are only as good as their data, which can be NOT GOOD.

Posted by: aafan | March 11, 2011 11:11 AM | Report abuse

Here, Ezra, here's one example.
Journal of Nervous & Mental Disease:
September 2002 - Volume 190 - Issue 9 - pp 583-592
Design and Reporting Modifications in Industry-Sponsored Comparative Psychopharmacology Trials

Collapse Box

This review of recently published pharmaceutical industry-sponsored comparative psychotropic drug trials aims to classify apparent design and reporting modifications that favor the sponsor's product. The modifications have been grouped into 13 discrete categories, and representative examples of each are presented. Strong circumstantial evidence suggests that marketing goals led to these adjustments. The consequences of marketing influences on comparative psychopharmacology trials are discussed in terms of conflicts of interest, the integrity of the scientific literature, and costs to consumers, as well as their impact on physician practice.

© 2002 Lippincott Williams & Wilkins, Inc.

Posted by: aafan | March 11, 2011 11:23 AM | Report abuse

Yes, Ezra. Language was included restraining CER from being the SOLE determinant in coverage and reimbursement for public programs. However, as you rightly point out, this was purely a political maneuver. No one in their right mind would ever think of conditioning access purely along CER lines.

I think the main issue is that those like Huckabee find this to be an easily exploitable political argument. Let's be clear, CER is a no brainer because it makes perfect sense conceptually. But the more practical details get complicated fast. And as we have seen with most other pieces of the ACA, these types of issues make for low-hanging fruit in assaulting health reform more generally since it is something that can be argued in simple black and white terms in ways that pit the political base against scary government.

Posted by: wilburonium | March 11, 2011 11:36 AM | Report abuse

Because Huckabee - and Republicans in general - have no interesr in seeing Medicare work better. They want to see it do worse - so much worse that they can finally kill it. Anything that shows that it can work effectively undercuts a core piece of their ideology.

Posted by: gilroy0 | March 11, 2011 11:37 AM | Report abuse

Medical treatments are highly personalized by the doctors to obtain the best patient healing outcome. A bureaucrat with or without an M.D. after his name can only guess what a good treatment is by using statistics. That treatment might win a cure for a lot of patients, but entirely miss the very one that a unique patient needs...we are all unique and not statistics.
We don't gamble with our health.

Posted by: denim39 | March 11, 2011 11:52 AM | Report abuse

Putting aside the disingenuous exhibited by the personal attacks on Huckabee, isn't all he saying is that the government shouldn't be making the decision as to which drug doctors can use?

He may be misinterpreting the theory behind CEER, but that doesn't mean his point doesn't have some validity.

He will never be president so he's strictly a sideline player. No need to disparage him, is there?

Posted by: Hazmat77 | March 11, 2011 11:57 AM | Report abuse

Obviously meant CER not CEER!

Posted by: Hazmat77 | March 11, 2011 12:02 PM | Report abuse

It would help if journalists called behavior of this sort by its usual name: subversion. Republicans today have more in common with anarchists than with conservatives of other historical periods.

Posted by: Chris48 | March 11, 2011 12:09 PM | Report abuse

In Conservlandia, every slope is slippery.

Posted by: arm3 | March 11, 2011 12:24 PM | Report abuse

As a number of persons have commented, making CER results the absolutely non-negotiable line in the sand is a probably a bad idea, but it's surely possible to include a reasonable amount of flexibility in the process (one size doesn't fit all).

That said, why WOULDN'T we want the information provided by CERs? (OK, we already know we certain pharmaceutical companies don't want us to have it.) Is evidence upon which to base decisions a bad thing??? The question of what to do with that evidence can be negotiated, but shutting off information never seems to be very smart. Death panels? Not even close, Mike. Either you know this, or you should. Really.

Posted by: post_reader_in_wv | March 11, 2011 1:59 PM | Report abuse

Huckabee's not going to like the comparative-effectiveness review of his decision to tour his book by running his mouth to every conservative radio host along the way.

"Use CER to determine the most effective treatments and then set reimbursment rates at the cost of that treatment."

It's not hard to imagine a more sophisticated version of the 'tarif de convention' used in France, where providers can bill whatever they like, but reimbursement stops at a published threshold. (Yeah, it's price-fixing, and what of it, given that the current alternative is the cowpucky of the UCR.)

Posted by: pseudonymousinnc | March 11, 2011 8:35 PM | Report abuse

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