Ezra,

Great article in the Baltimore Sun. Two points:

In the future, some experts say, approved medical tests and treatments could be treated the same way prescription drugs are now: Patients would pay little or nothing for generic drugs or "high value" procedures and higher co-payments for treatments judged to be of "low value."

This is my proposed approach as well, which is Consumer Directed Health Care, by any reasonable definition. I think you agree, but your frequent derision of CDH as a concept gives me pause-- care to clarify on this issue?

Prostate cancer, which occurs in older men, illustrates both the potential savings and the potential controversy of the "best value" approach.

If the cancer is discovered before it has spread, doctors and patients have several options. They can choose so-called "watchful waiting" to see how the normally slow-growing tumor progresses. Chemotherapy is another possibility. But radiation is increasingly the option of choice because of the relatively lower level of side effects.

Three-dimensional CT-scan images are used to aid in focusing X-rays on the tumor while sparing surrounding tissue.

Over roughly the past five years, intensity-modulated radiation therapy, commonly called IMRT, has become practically standard in this country. But a panel of scientists, including Tunis, recently conducted a study comparing IMRT to an early radiation regimen called 3-D CRT.

The panel analyzed medical studies on the two treatments. The conclusion: Both were about equally effective at zapping tumors and preventing the cancer from returning.

But IMRT - the newer treatment - costs about four times as much as the older approach: $42,450 compared with $10,900.

A opportunity to save health-care dollars? Yes, the panel concluded: Using the far more expensive regimen was a "low value" choice.

But some critics say long-term effectiveness is not the only consideration. Treating prostate cancer with radiation can damage healthy tissue near the tumor. That sometimes inflames the digestive tract and can cause pain and diarrhea. The side effects usually clear up in weeks or months, but they are distressing while they last.

I excerpted this primarily because it illustrates how complicated doing this research really is. I'd add that the side effects can be adequately accounted for in a good cost-effectiveness model. At the same time, however, there are different types of patients with prostate cancer-- different tumor staging (i.e. severity of the cancer) age, co-morbidities, etc.-- all of which could change the value equation for a given sub-set of patients. Not saying this isn't a goal to strive for, but people need to appreciate the level of complexity involved, and the above example is a good one.

that a new comparative effectiveness board will have powerful political defenders (like insurers and the business community)

This raises an interesting point.

In a single-payer system, both of these constituencies go away, and you're left with government administrators pushing back against doctors that are claiming that quality of care is being denied. Constituents get angry, politicians get phone calls, and the government administrators get overruled. Your reliance on the "defenders" above is a very important reason why an improved market system will function better. Someone needs a reason to hold down costs-- it ain't going to be politicians.

For this round of the political game, it's the "insurance," stupid. "Cost control" is wonkish stuff that benefits no one for the next 20 years. Fear of financial disaster tomorrow haunts 50 million Americans now. Fear of financial disaster six months from now after a job is lost -- who can afford COBRA? -- haunts another 250 million Americans. Fear of uncapped increases in benefit costs haunts several million employers. "Cost control," sure we all know it's a concern that's tough to solve. IT'S THE INSURANCE, STUPID. Important people read you: make that point over and over.

Further, national health insurance is a macroeconomic measure, tied in with other economic measures through the concept of "consumer confidence" as well as investor and employer confidence. Confidence across the board has tanked. Fear of the future is hardly the way to rebuild an economy. Universal health insurance is a fundamental structural change that is a genuine, life-changing benefit for all Americans, far more significant than a $1000 stimulus hit, more than minimum wage, more than jobs programs.

Just as patients nationwide rejected the HMO capitated gatekeeper model of healthcare, they will also reject the model in which the government "clears" you for back surgery only after undergoing conservative physical therapy for 6 months first.

joe blow is possibly right, but the real reason people rejected HMO's gatekeeper functions is not because the HMOs were denying them what they wanted or needed but because they believed the HMOs only had one motive for doing so: profit. The National Institute for Health and Clinical Excellence (NICE) in Britain doesn't have an incentive to find treatments ineffective. They don't make money by rejecting patients or doctors, they're just looking at the evidence. Couldn't we do the same in the US?

SteveH,

That’s a little naïve, NICE and NHS have budgets, every dollar they spend comes from taxes, if cost are greater then available tax resources politicians are either forced to raise taxes or cut benefits. How do you think they would cut benefits? Tell NICE and NHS to disallow services or lower reimbursements or something.

It would be nice if all you people talking about HC reform would take two minutes and read a little history. HMOs where our NICE/NHS. Congress specifically and clearly stated their goal was for all American’s to be enrolled in HMOs which are directly regulated by Congress. HMOs where to be the degree of separation needed to allow Congress to control the purse strings of Health Care without taking the political bumps. No politician wants to be blamed for denying Grandmas treatment, so they do it through the HMO. Congress funded the start up of HMOs and the goal was to subsidize the majority of the premium thus effectively controlling them.

We have been down this road before and we hated it. Why are we going back to the same clowns that gave us the bad directions to start with?

The majority of doctors I know are perfectly friendly towards comparative effectiveness studies. There's a few exceptions, and they tend to be toadies of the insurance companies.

When there's a lack of data, it's often because the government isn't funding these studies. The industry groups, naturally, fill the void.

It's simply not very controversial amongst doctors that this is not the best way to do things. We all agree that medicine should be evidence-based, and that's the catch-phrase that's been animating all of the major academic work in the past decade.

Once again, there's not much conflict or controversy over this issue. There no secret conspiracy of doctors who oppose evidence-based research.

Err, correction to the above, I mean they tend to be toadies of the drug companies, not insurance companies...

If my comments and inbox were any indication, that post pissed a lot of people off.

Blaming various problems on the AMA or the trendy, new "doctors' guilds" is sort of annoying -- kind of like the "Democrat Party". It doesn't make any sense, it just makes it clear that you don't, um, exactly know what you're talking about. Frankly, it's sloppy and you seem capable of better.

On Saturday you dissed angioplasty. Here's a new study (done by a Swede with data from the UK's NHS):
http://www.medscape.com/viewarticle/575652_print

American doctors are basically a union for thieves. They band together and restrict competition to increase their (already stratospheric) incomes. Its time for ordinary taxpapers to stand up to them. Ditto for dentists.

Urban Legend--
Look at health insurance
premiums and look at health
care spending on drugs, devices, hospitals, doctors,
nurseing homes, and you'll
find that health insurance premiums have risen in line with rising costs in all of these areas--a combination of volume (more drugs, more procedures) and higher prices for every thing.

Health insuers' profits and overhead as a percentage of what they collect in premiums has remained relatively constant. (The only windfall they're enjoying is the huge, unjustified bonus that Congress voted to pay insuers who offer Medicare Advantage.)

Premiums have been going up because the cost of healthcare has been going up.

In the 1990s, insurers tried
to fight rising costs by trying to "manage" care. Unfortuantely, they did a poor job of it--refusing to cover treatments largely based on their price rather than based on reserach as to whether they are effective.

On Comparative Effectivess Research: We desperately need unbiased research comparing drugs, devices and procedures. And it has to be insulated from Congress and the lobbyists. This is going to be very, very difficult.

One way to do it is to make sure the Institute does not have to go to Congress for appropriations. If it had a dedicated stream of funding, that would help.

Secondly, in the U.K., their version of a Comparative Effectiveness Institute (NICE) is funded by goverment, but once NICE makes a decision, it does not
have to go back to parliament for approval.

Instead NICE's decision becomes "law" in the sense that the National Health Service then has to pay for the procedure, device or drug that NICE has ruled is most effective.

And NICE's recommendation is then sent out as a "best practice guideline" (not rule) to doctors and hospitals. Doctors and hospitals do not have to follow the guideline, if in a particular case, they don't think it's appropriate.

Right now NICE has about 89% compliance.

It's not a bad model.

I'm talking only about November 2008 through the time the first plan is on the boards. Most Americans know cost control, is important, but they also know its difficult. Democrats (including Obama) believe in a central government role to get us to universal or near-universal health insurance. Republicans do not, and therefore do not understand the proble. I would contend that, for November 2008 through the time the first actual plan is adopted, even liberals who spend time talking about cost control -- which will not eliminate the fear of American workers and employers -- don't understand the problem, either.