Surely someone has already suggested this, but why exactly shouldn't Federal comparative effectiveness research be delivered by leggy former cheerleaders?

Where is Jonah Goldberg? He believes in more market based health care and you can't have a market if the information is hidden! Its almost like those conservative plan boosters don't know what they are talking about!

You're pretty much proving my point from yesterday. Pharma controls their data-- that's correct. At least they have data. Hospitals and physicians are treatment patients with surgeries and other non-drug related treatments with significantly less data than we have on drugs. We spend $250 billion on drugs, and $1.3 trillion on hospitals and physicians. Again-- Drugs have data. Hospitals and physicians have significantly less on their practices. How is it possible that government's first focus is on providing better data on drugs, rather than sufficient data on other treatments? Ezra, how do you just simply go along with this thinking? KevinMD's opinions are pretty obvious-- he's a doc who doesn't think government needs more oversight of his medical practice. But the Wennberg/Berwick thinking isn't about using too many expensive drugs. Its about getting the actual medical practice to adhere to a set of standards and stop undertaking unnecessary procedures, treatments and visits. The 30% waste point is a little about drugs, but much more so inappropriate variation in care and non-adherence to EBM.

Your Miss America picture just completes the picture of a shallow, misunderstood depiction of cost reform in health care. Berwick and Wennberg aren't focusing on Miss America contestants turned sales reps-- why are you?

PS Just to clarify-- everything you said in this post is correct. Its just not the important issue in driving cost-savings. If we had a policy reform that was addressing drug costs and other health care costs by improving medical practice-- I'd be extremely supportive. But instead, were going down a path where politicians in DC will make themselves feel good that they enabled a way of saving $20-50 billion in annual drug costs, while avoiding the much tougher problem, medical practice. You posted other posts in the past that suggested you understood health care cost drivers, but instead you seem to be drawn in by the current battles in DC on CER and are losing the big picture. So my frustration is that if you're not able to see the big picture, who in DC will?

wisewon,
I was under the impression that provider compensation was only ~15% of total healthcare costs. What are you referring to exactly when you say we spend however much money on "physicians and hospitals?" Could you unpack that a little more?

Total system cost $2,100B

1) insurance companies-- $150B (includes government admin also)
2) physicians-- $650B
3) hospitals-- $650B
4) drug/medical device companies-- $275B
5) long-term care facilities-- $175B
6) other

Source:

http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf

One quick note-- I copy and pasted this from an old post, and as such, the 2007 data is now available from CMS, whereas my numbers above are from 2006.

What's changed?

Providers and hospitals are up another $100 billion, drugs/devices up $15 billion.

Again, why aren't we focusing on the former?

Thanks. I agree with your overall point, but wouldn't a substantial portion of comparative effectiveness money go towards comparing things like surgical vs medical management? That seems like a good way of testing the usefulness of surgery for many conditions.

Wisewon:
The original posting did not say that the comparative effectiveness studies will be limited to drugs.

It said "With treatments and medications announced daily, having an entity definitively compare these newer, and often more expensive, options with established treatment regimens will be particularly useful in everyday practice."

Why does that imply to you that only drugs will be studied?

Although I'm still trying to run this down in detail, I suspect there's a bigger problem with wisewon's numbers. CMS doesn't seem to define the terms it uses in the NHE data -- or if it does, it's hidden the info pretty well -- but if you take the table's line-item descriptions at face value, wisewon seems to be assuming that "Retail Outlet Sales of Medical Products" accounts for all U.S. drug and device spending.

In fact, though, I suspect a huge amount of device spending -- and some drug spending as well -- actually flows through the line items for "hospital care" and "professional services." Doctors and hospitals aren't buying their drugs and medical equipment through pharmacies and other retail outlets -- they're buying them wholesale and then billing insurers or the government for their use. And that's almost certainly where these expenditures are turning up in the NHE data.

That's particularly true for big-ticket items like MRI and CAT scanners, radiation-treatment centers, etc. It's probably also true of stents and other devices used in many surgical interventions.
And overuse of some of these technologies does account for a lot of "wasted" medical spending.

Nobody who's serious about this debate questions the need for changes in medical practice. But doctors are frequently extremely slow to adapt new ways of doing things and independent-minded enough to resist attempts by federal or hospital bureaucrats to tell them what to do. While there are lots of good ideas about how to change the incentives to minimize overtreatment and to emphasize outcome quality and patient safety, they are all going to take quite a bit of time to enact.

So this is not the sort of problem that anyone was likely to tackle in a stimulus bill thrown together on short notice in order to prevent the economy from collapsing. CER is relatively easy to fund by comparison, and so Congress threw some money at it. That's hardly the end of the story.

Nor should anyone think that CER is limited to head-to-head trials of competing drugs, although that tends to be the first thing many peopel think about. brocktoon is right; there's lots to be learned by comparing surgical interventions to less aggressive practices, or by developing hard data as to when it makes the most sense to order an MRI instead of an X-ray, and so forth.

The answer is simple enough: Comparative effectiveness isn't limited to drugs. But pharma has been the most aggressive player opposing comparative effectiveness. This post is about that opposition. Hence it focuses on pharma. The medical device industry simply isn't as coherent a lobbying force.

David,

Reasonable post. A couple of responses:

--Some drug spend isn't included in the numbers are you suggest-- estimates are that roughly another $100 billion should be on the durg/device line rather than the physician/hospital line.

-- My comments aren't focused on the stimulus bill. While the rest of the health reform package is still TBD, there is ample information on the plans for the Democratic candidates, Baucus plan, CAP plan-- CER has a disproportionate focus compared to changes in medical practice.

The answer is simple enough: Comparative effectiveness isn't limited to drugs. But pharma has been the most aggressive player opposing comparative effectiveness. This post is about that opposition. Hence it focuses on pharma. The medical device industry simply isn't as coherent a lobbying force.

Ezra,

That's a silly response. NICE isn't only about drugs, technically also. But it pretty much is. AS I wrote yesterday-- the whole debate over "comparative" vs. "clinical" effectiveness really has to do with the balance of drugs vs. others. The other don't even have the clinical data, for the most part. "Comparative" effectiveness assumes clinical effectiveness has already been established, which is really only true for drugs. That's the point. Claiming it isn't just for drugs is disingenuous-- it disproportionately is going to be the focus. Just like NICE. Just like Obama and other Democrats campaigned for the past two years.

There already have been some extremely helpful studies in psychiatry that, while not comparing drugs head to head, show the efficacy of certain types of drugs.

This has been helpful in my practice because it negates the constant blather from the various drug reps as to why their particular drug is "the best." For example, there is no credible information that shows that a new drug (I won't name names as it appears to be true across the board) heavily advertised on TV and in magazines directly to patients is any more helpful than a $4 generic from WalMart or Target. If you read between the lines in the studies you will see that all of the drugs in this category have about the same efficacy. There are credible (meaning not funded by the companies) studies showing that some of the older drugs out perform the new ones by barely significant numbers.

What is disturbing is that the drug companies know my prescribing habits - have known them for twenty years due to a deal with pharmacies - and they attempt to direct me elsewhere. The only way to avoid this is to not see the drug reps, something I am more than willing to do because 1) although they may be cute or folksy (the men) I still know more than they do about the treatment of disease and 2) that 15 minutes could be devoted to patients (and if you are still not convinced, it costs a lot of money to see a rep.)

Add the fact that drug companies often ghost write articles for prominent authors, pay them millions of dollars to push their product and engage in other corrupting practices, it is imperative that some third party help by doing honest comparisons.

I think mikeyes sort of proves wisewon's point about CER being primarily a question about drugs (and by extension, somewhat about devices): we have some comparative studies that have begun to ask if some "new" drugs really are the improvements in treatment they claim to be. Because we've moved to a system of care that looks for a pharma solution often first, it's a good question.

The point, as wiseon and I and others have been trying to make... is that it's not the only question. What we're not asking is how a drug therapy compares to an alternative approach... and part of the reason we're not asking is because,as wisewon suggests, drug companies have defined the notion of "outcome": that is, we see a problem, we ask if the treatment solves the problem (clinical effectiveness). This is great for things that can be, say, cured, or fixed. It's less clear when the "outcome" is, say, greater range of motion, "better" "quality of life" (hence the reason psych drug studies have a kind of notorious rep for not proving very much), or other similar, rather nebulous concepts. We can ask, after heart surgery, if you are, say, still alive. We can't know, exactly, after brain surgery, if you got the best brain, or even a better one, because of it. So how do we compare different approaches to brain surgery? How do we compare a brain surgery to a drug treatment?

What we will do with a lot of this money is some good basic research, that likely will help us debunk some notions about "breakthrough" drugs and "novel" therapies. We may even do longer studies to compare different surgical procedures, or combinations of surgeries and drug therapies (some cancers, heart disease, most likely). But there's a lot of things where doing outcomes based, comparative research is next to impossible... because we've never asked basic questions about outcomes to begin with. Or because we've accepted some outcomes as good enough... and not asked if we can demand better ones.

Good criminy -- if a doctor is stupid enough to trust a hot sales rep (who, let's not be shy, is being paid to lie) over reading the fucking journal article and making up his own mind, he shouldn't be practicing.

Nothing Ezra is saying isn't true. He's just leaving some stuff out:

1) How will this be researched? Will it require the government to have our medical records in order to find out the effectiveness of medical treatments? If so, that's an unacceptable breach of our privacy.

2) Will the government use it to decide what they will cover, or will it just be a tool for doctors that is more reliable than pharma industry propaganda? If it's the former, it's a serious problem. If it's the latter, that's great.

True, with so many researches happening in the field, there has to be an authority that compares these researches and suggests the best treatments for ailments. This does not only ensure the best treatment to patients but also ensures that the trial methods often used for treatments are curbed.

Consumer Reports Best Buy Drugs (http://www.consumerreports.org/health/best-buy-drugs/index.htm) provides consumers with independent research and recommendations on the most cost-effective prescription drugs for most common health conditions.