The Obama administration has made a major investment in comparative effectiveness research (CER) to learn what treatments work best for which patients. CER has the potential to reduce wasteful medical spending and improve patient outcomes, but the political sustainability of this initiative remains unclear because of concerns that it will threaten the doctor-patient relationship. An unresolved question is whether it is possible to boost public support for the use of CER as a cost-control strategy. We investigate one potential source of public support: Americans’ trust in physicians as faithful agents of patient interests. We conducted two national surveys to explore the public’s confidence in doctors compared to other groups. We find that doctors are viewed as harder workers, more trustworthy, and more caring than other professionals. Through survey experiments, we demonstrate that the support of doctors’ groups for proposals to control costs and use CER have a greater influence on aggregate public opinion than do cues from political actors including congressional Democrats, Republicans, and a bipartisan commission. Our survey results suggest that the medical profession’s stance will be an important factor in shaping the political viability of efforts to use CER as a tool for health care cost control.
Doctor Knows Best: Physician Endorsements, Public Opinion, and the Politics of Comparative Effectiveness ResearchFebruary 17, 2014
Efforts to support and use comparative effectiveness research (CER), some more successful than others, have been promulgated at various times over the last forty years. Following a resurgence of interest in CER, recent health care reforms provided substantial support to strengthen its role in US health care. While CER has generally captured bipartisan support, detractors have raised concerns that it will be used to ration services and heighten government control over health care. Such concerns almost derailed the initiative during passage of the health care reform legislation and are still present today. Given recent investments in CER and the debates surrounding its development, the time is ripe to reflect on past efforts to introduce CER in the United States. This article examines previous initiatives, highlighting their prescribed role in US health care, the reasons for their success or failure, and the political lessons learned. Current CER initiatives have corrected for many of the pitfalls experienced by previous efforts. However, past experiences point to a number of issues that must still be addressed to ensure the long-term success and sustainability of CER, including adopting realistic aims about its impact, demonstrating the impact of Patient-Centered Outcomes Research Institute (PCORI) and communicating the benefits of CER, and maintaining strong political and stakeholder support.
Design and Implementation of N-of-1 Trials: A User’s Guide – Research Report – Final | AHRQ Effective Health Care ProgramFebruary 16, 2014
AHRQ commissioned this User’s Guide as an informational resource to researchers, health care providers, patients, and other stakeholders to improve general understanding of n-of-1 trials and strengthen the quality of evidence that is generated when an n-of-1 trial is conducted. The overarching aim of this User’s Guide is to guide readers by identifying key decisions and tradeoffs in the design and implementation of n-of-1 trials, particularly when used for patient-centered outcomes research. Patient-centered outcomes research includes investigations of a wide range of research problems, particularly studying the outcomes, effectiveness, benefits, and harms of diagnostic tests, treatments, procedures, or health care services. This User’s Guide identifies key elements to consider in applying the n-of-1 trial methodology to patient-centered outcomes research, describes some of the important complexities of the method, and provides readers with checklists to summarize the main points.
In more and more countries, ratings of medicines have become part of the already lengthy process that stands between new treatments and the patients who might be helped. Some ratings take the form of medical-benefit or innovation scales that try to predict the contributions of new medicines to health outcomes, often by comparing new and existing treatments.
In France, for example, the so-called Medicines Evaluation Commission uses a five-point scale ranging from “no improvement” to “major innovation” to rank new medicines against treatments already in use. A recent study of all 10 cancer medicines launched between 2003 and 2005 found that not a single one received a “major innovation” rating from French authorities—though several went on to become widely recognized standards of care.
Other systems—such as England’s—place the new medicines on cost-benefit curves, declaring whether or not they have met certain thresholds before the National Health Service will pay for them. These efforts are known as Health Technology Assessment or comparative-effectiveness research, or CER. Thanks to ObamaCare, CER now is heavily funded in the U.S. It is intended to evaluate established treatments but could evolve quickly into a gate-keeping system….
These efforts have two critical problems. First, it is almost impossible to predict the ultimate value of new treatments before they have been used widely in the actual practice of medicine. Second, expectations about outcomes that dismiss what appear to be small improvements ignore the very nature of progress against cancer. Science, medicine and public-health efforts have moved forward against cancer not in giant leaps but incrementally.
Making the case for annual mammograms is Marisa Weiss, president and founder of Breastcancer.org and director of breast health outreach and breast radiation oncology at Lankenau Medical Center, Wynnewood, Pa. Arguing against routine annual screenings is H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and an author of “Overdiagnosed: Making People Sick in the Pursuit of Health.”
I think it is just perfectly clear that the government has forced a needless and completely avoidable confrontation and has knowingly put many religious believers in an impossible situation. It is no secret that most of America’s largest religious denominations are opposed to abortion, and that some are opposed to contraception as well. And there are many alternative means by which the government can (and does) make abortive and contraceptive drugs and procedures available to people. The purpose of refusing to provide a religious exemption from this rule would therefore appear to be to force religious employers themselves to make those drugs and procedures available—to bend a moral minority to the will of the state. It is not only a failure of statesmanship and prudence, it is a failure of even the most minimal toleration.
There may be a debate over whether Obamacare’s individual mandate is a penalty or a tax, but there is no debate among doctors and their patients about the fact that Obamacare will be bad for America’s health.
Democrats and Republicans share a fundamental misconception about medical care. Both assume that, as in mathematics, there is a single right answer for every health problem. These “best practices,” they believe, can be found by gathering large amounts of data for experts to analyze. The experts will then identify remedies based strictly on science—impartial and objective.
Yet in medicine, there are many contrary opinions about “best practices.” You cannot pick up a newspaper, turn on the TV or surf the Internet without encountering conflicting reports about various tests and treatments. Medical experts disagree about many issues, often dramatically.
As appealing as it is – as useful as it is – to imagine that there exists a gold-standard way to practice medicine, and a single-best way to approach most human ailments, the reality is considerably more complex and messy, as Hartzband and Groopman’s (continued) critique of so-called “best practices” makes clear.
The heart of their argument is this: “For patients and experts alike, there is a subjective core to every medical decision. The truth is that, despite many advances, much of medicine still exists in a gray zone where there is not one right answer. No one can say with certainty who will benefit by taking a certain drug and who will not. Nor can we say with certainty what impact a medical condition will have on someone’s life or how they might experience a treatment’s side effects. The path to maintaining or regaining health is not the same for everyone; our preferences really do matter.”
White Coats and Straightjackets: Why Planned Cost-Saving Measures Will Reduce Your Healthcare Options — The American MagazineMarch 7, 2012
Before we proceed with the Independent Payment Advisory Board, we should carefully consider the pernicious impact that similar structures have had on patient care.