Wednesday, April 29, 2009

The Federal Urge to Spend: The Comparative Effectiveness Institute

Washington is thinking of spending tens of billions of dollars on a Comparative Effectiveness Institute, based on a concept borrowed from Great Britain (The National Institute for Health and Clinical Excellence). However Great Britain has adequate primary care. We do not. And Great Britain has put a dollar limit on a newer drug or procedure regardless of its potential for benefit for that particular individual, while the U.S. Congress has rightfully ruled that out for our citizens.

The biggest flaw in the need for the Institute is the assumption that American doctors do not know how to practice medicine that delivers value for the dollar, and that information on this subject does not now exist. This idea is categorically false! Physicians know very well from many existing studies when further critical care will not be beneficial, when cardiac catheritization and stenting is not warranted, when multiple transfers from nursing home to hospitals will not benefit the patient and so on. I am not discussing debatable situations, rather situations that are manifestly obvious.

It is not a lack of knowledge underlying the cause for all this inappropriate care. The culprits have been previously discussed on this blog, for instance: perverse financial incentives including excessive reimbursement for technology, inadequate primary care, fear of legal consequences, and lack of national medical standards. If you want to read up on it, get a copy of The Dartmouth Atlas of Health Care: Regional Disparity in Medicine.

On this blog I have proposed multiple steps to more effectively deal with these problems:
1) Through the Federal Health Care Clearing House and Bank, prospectively verify the benefit of newer therapies via funding of their confirmatory research through the National Institutes of Health before they are approved for general use. This information would be generated via well-performed excellent studies reported without bias.
2) Use of my new admitting form that clarifies that only beneficial care can be delivered.
3) Physician review through Appropriate Care Committees to guarantee as much as possible that care will be beneficial and uniform throughout the country.
4) Amendments to the Patient Self Determination Act, the Americans with Disabilities Act and the Emergency Medical and Active Labor Act to include the phrase, “within acceptable medical standards.”

We can provide universal coverage and decrease our percentage of gross domestic product devoted to health care. If other industrial nations throughout the world can it, so can we. And we can do it without spending billions to study this, that, and the other, when the information is already out there. However, the sense from Washington is that we have to spend many billions more before we can reduce spending. I completely disagree!

A congressional budget office 2008 report quoted in the April 7, 2009 Annals of Internal Medicine states that a Comparative Effectiveness Institute in the United States would reduce health care spending by less than one tenth of one percent. There is no doubt in my mind that my plan is far superior. Do you agree?


Thaddeus Mason Pope said...

Dear Dr. Fisher:

I have enjoyed reading your book and blog, especially as it pertains to ethics committees. I used it in my forthcoming article "Multi-Institutional Health Care Ethics
Committees: the Procedurally Fair Internal Dispute Resolution

A copy of the prepublication version is available here

I welcome any comments and criticisms. And I am happy to
provide any sources.

Best regards,
Thaddeus Pope

Thaddeus Mason Pope, J.D., Ph.D.
Widener University School of Law
4601 Concord Pike, Room 325
Wilmington, Delaware 19803

T: 302-477-2230
F: 901-202-7549

Doctor Kenneth Fisher said...

Dr. Pope,
Thank you for supporting comments. I agree with the need to develop better methods of conflict resolution between decreasing non-beneficial inappropriate care and the expectations of the public. I have e-mailed to you my policy paper and look forward to your comments. Kenneth A. Fisher, M.D.

Michael Kirsch, M.D. said...

Dr. Fisher,

Nice blog. Regarding your position in your posting: "Physicians know very well from many existing studies when further critical care will not be beneficial, when cardiac catheritization and stenting is not warranted..." It's not sufficient what we physician know; what matters is what we do. My own blog is entirely devoted to medical quality and has a focus on eliminating excessive medical care. I think that physicians, who order every CAT scan, consultation and medication, are uniquely poised to control excessive care which would reduce costs and raise quality.

Doctor Kenneth Fisher said...

Dr. Kirsch,
Thank you for your comment, I would be very interested in your thoughts about my ideas regarding physician based appropriate care committees. Kenneth A. Fisher, M.D.