Do we want to know what works in health care?

Bob Berenson of the Urban Institute and Beth Docteur of the Center for Studying Health Systems Change write about how comparative effectiveness and comparative effectiveness research, concepts that have been frequently referenced in recent health reform debates, could potentially affect the quality of health care that Americans receive.

Much of the debate about taking action on health care reform, particularly in recent times, has had the unintended effect of obfuscating the  ideas that might really help fix our health care, instead of giving us an objective basis to judge whether they’re any good.  That’s why politicians and talking heads can heatedly argue about ideas like public options and individual mandates  while the vast majority of the American public go through stages of hope, bewilderment and even outright fear about what they’re going to gain, or lose, under different versions of health reform legislation. 

To a certain extent, the loosely-based-on-fact rhetoric on health reform is understandable, given what a staggeringly complex beast American health care has grown to be—the Nine-Headed Hydra is nothing compared to the vast industry that costs us so much, delivers state-of-the-art care to some Americans, yet leaves so many others without access to good health care.  But as our national leaders continue to grapple with the details of the reform, we policy analysts and researchers still need to help by focusing some of our energies on clarifying what’s what in terms of key concepts and ideas that have dominated the health reform debate.  So, already, we at the Urban Institute, with RWJF’s support, have looked at how the quality of U.S. health care stacks up internationally, finding evidence to dispel some myths about supposed U.S. superiority; and we have also tried to shed light on so-called accountable care organizations, a concept that offers real potential but faces significant challenges, not least of which is achieving a consensus about what an ACO actually is.

Our latest policy paper is about yet another concept that has cropped up frequently in health reform debates, even before the stimulus funding—comparative effectiveness.  Comparative effectiveness is, simply, about how evidence from various kinds of research, might help inform the decisions of physicians, payers, and patients about which diagnostic tools and treatments work best for particular patients with particular conditions.  Comparative effectiveness is about the notion that if, say, you are faced with a decision about what to do about a new (and troubling) development in your heart condition, you might want your doctor, and yourself, to have access to the best available information that can help you make more “informed” decisions about your own care, consistent with your own values and perspectives.

While the notion of using information to make better decisions should be fairly uncontroversial, remarkably, in health care it is not.  Because comparative effectiveness is one of those concepts that, while innocuous on its face, raise all sorts of bogeys about potential misuse.  Patients and consumers, for example, are being scared by the view that the application of information about what works and doesn’t work in diagnosis and treatment options is a thinly veiled attempt to “ration” health care.  The truth of the matter is, much health care IS rationed already, according to the ability to pay for health care. But most people don’t see it quite that way, and are more apt to focus on what they might lose, rather than what they might gain, under a more rational health care system.  And some doctors view the use of comparative effectiveness research as a threat to their autonomy and ability to use their own judgment in treating individual patients, rather than as a tool to help them serve their patients better. Yet, as the policy paper points out, dozens of organizations representing physicians have strongly endorsed comparative effectiveness and want it to proceed expeditiously.

Our purpose, with our latest paper, is not to suggest that comparative effectiveness is either the silver bullet or the bogey in health reform—it is, like our other papers, an effort to explicate the concept so that policymakers make decisions based on what they can know, rather than make decisions based on distortion and myth.