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Authoritative Center Urged for Comparing Value of Treatments

By John Reichard, CQ HealthBeat Editor

February 14, 2007 -- A panel of leading health policy analysts said Wednesday that Congress should no longer delay in creating an entity that would compare the value of health care treatments. With health costs rising at unsustainable rates, authoritative research comparing the effectiveness of drugs, devices, and medical procedures for given medical conditions would provide a way to bring spending down to sustainable levels, the analysts said at an industry-sponsored forum.

Brandeis University professor Stuart Altman, one of the panelists, said that the brakes must be applied on health care spending growth, but in an organized and systematic fashion, not in a "scared" way.

"We do not in this country compare . . . at a fundamental level the benefits to the costs" of care, he said. "We are one of a very small group of countries that don't do it. Other countries—England, Australia, Canada, Israel, Germany—all have various degrees of federal action looking at comparative effectiveness, how well does this technique or technology or procedure work in comparison to another one."

"There are places in this country where people are dying from getting too much care," he said, citing the research of Dartmouth researcher Jack Wennberg. The way to address that problem, Altman said, "is to really understand what works, and what doesn't." Short of that, care will be restructured in a "haphazard way."

Gail Wilensky, who headed the Medicare and Medicaid programs in the administration of George Herbert Walker Bush, echoed Altman's warning that health care spending is growing at an unsustainable pace, saying that even if the Iraq War winds down and there is a "peace dividend," and even if the Bush tax cuts are allowed to expire, there won't be nearly enough money to keep up over the long run with current health care spending increases.

The 2 percent or more that health care spending is growing faster than inflation must be brought down to something more sustainable, such as half a percent or 1 percent, she said.

Getting to that point will require an investment in comparative studies, which in effect would be an expansion on what the Food and Drug Administration does. Currently, the agency only compares drugs to placebos in deciding on safety and efficacy, but similarly rigorous evaluations need to be performed that compare the safety and effectiveness of medical procedures, she said.

An investment of "billions" of dollars, not millions, will be required, she said.

Wilensky warned that the entity given responsibility for comparing clinical effectiveness of treatments should not be the entity that compares cost-effectiveness of procedures or determines whether insurers will cover a given procedure. That would bring political pressures to bear on the entity and doom its efforts, she suggested.

Instead, the entity should merely provide data on clinical effectiveness that could be used by payers as they make coverage decisions. Wilensky said it's highly likely that such an entity would be able to slow spending growth through its research. "We won't know 'til we try it," she said.

Jack Rowe, who retired from his position as chief executive officer of the giant health insurer Aetna in late 2006, said the work of a comparative research center would be "very widely adopted" by insurers and employers. "If you build it, they will come," he said. Employers "are dying to have this," he said.

Rowe said he would go further than Wilensky, however. "I would mandate that Medicare follow" the recommendations produced by the research entity on which treatments work best. But Rowe agreed with Wilensky on how patients should be guided to better treatments, praising the idea of having lower copayments for those treatments.

Speakers expressed concern about having the entity placed in what Rowe called "an immunologically privileged zone" where its budget could not be zeroed out by lawmakers under the influence of powerful health care lobbies adversely affected by research findings. Among the models suggested were creating an independent scientific entity along the lines of the Institute of Medicine or creating a public–private organization.

Kathleen Buto, vice president for health policy at the drug and medical products giant Johnson & Johnson, expressed caution, saying the research entity should have "broad stakeholder participation" in setting its research agenda, and that guidelines that might result from its work should be flexible enough to allow for the fact that individuals may vary in how they respond to treatments. She also expressed some hesitancy about whether the work involved would necessarily save a lot of money, saying she is "a little worried" that it's being regarded as "the new silver bullet."

Before joining J&J, Buto was a senior analyst at the Congressional Budget Office and before that was a senior adviser to Medicare on reimbursement policy.

Legislative efforts to create an entity to conduct comparative effectiveness research are expected in the near future. "We have been meeting with members from the House and Senate in response to a growing congressional interest in comparative effectiveness research," said David Helms, chief executive officer of AcademyHealth, an organization that represents health services researchers. AcademyHealth has laid out various options for how such an entity might be structured and where it might be located.

Rowe said attention should be paid to training more health services researchers if such an entity is developed. "I'm not sure we have all the people to do the analysis that needs to get done," he said. Rowe is a former member of the Medicare Payment Advisory Commission, served for years as president of the Mt. Sinai Hospital and School of Medicine in New York City, and is now a health policy professor at Columbia University.

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