By Sara Lubbes, CQ Staff
April 4, 2008 -- As health care costs rise across the country, members of Congress are struggling with whether the government should force the health care industry to test the outcomes of different therapies for the same condition against each other to see what method really does work best for patients.
But at a forum on Friday sponsored by the Alliance for Health Reform, private health care professionals and industry academics said that they, too, believe that so-called comparative effectiveness is the best way to allow providers and patients to avoid ineffective or wasteful treatments and to make sure people get the best care.
However, the experts disagreed whether insurance companies should be allowed to base their health care coverage on the effectiveness of one drug compared to another.
"Comparative effectiveness should not be used to deny coverage for a safe and effective treatment," said David Nexon, a spokesman for the medical device industry group Advanced Medical Technology Association (AdvaMed) and former health advisor to Edward M. Kennedy, D-Mass.
"Making blanket coverage denials is wrong," he said.
Announced at the forum were the results of a January 2008 Institute of Medicine committee review of comparative effectiveness methods.
The report calls on Congress to create a semi-private government agency that would conduct reviews comparing existing and new medical treatments to determine the treatments that work best for various conditions.
The agency would allow insurance companies and non-profit agencies from duplicating each other's work. The committee reviewed seven organizations—including health insurers UnitedHealthCare and Kaiser Permanente—and found that all seven separately reviewed the same 14 drugs or treatments independently.
Under the congressionally mandated agency, that drug-evaluating work would be done at one central location.
The Agency for Healthcare Research and Quality (AHRQ) is already doing some comparative effectiveness work and could serve as a model for the new agency, said Wilhelmine Miller, an associate research professor at George Washington University who directed the IOM study.
The IOM study did not include an investigation of whether comparative effectiveness can cut health care costs. But Karen Ignagni, president and CEO of America's Health Insurance Plans, a trade association representing 1,300 health insurance firms, said to ignore the idea of using comparative effectiveness to cut health care expenses is "like putting our heads in the sand." "Not to look at comparative effectiveness as a basis for [insurance coverage] determinations makes no sense to us," Ignagni said.
AdvaMed's Nexon disputed the notion that insurers would bar a patient from a treatment because it had failed a comparative effectiveness test. He said the tests are based on what works best for a 'normal' patient, but not all patients are the same.
Carolyn Clancy, director of AHRQ, noted that the results of a comparative effectiveness review are rarely cut and dry—instead of finding out that one drug is far superior to another similar product, the agency more often than not finds that every drug works, but some are better in certain circumstances.
Clancy said the most important thing to do as the government and private companies work together to expand comparative effectiveness efforts is to make sure the process is as open to public review as possible.
"If everyone can see and understand the work, then there will not be a 'black box," she said.