Tuesday, February 02, 2010

Obama's comparative effectiveness agenda: tools versus rules

Jerome Groopman's recent piece in the New York Review of Books is a must read for anyone who's serious about health policy. His opening paragraph reveals the President's naiveté about scientific medicine:

The administration's stimulus package already devoted more than a billion dollars to "comparative effectiveness research," meaning, in the President's words, evaluating "what works and what doesn't" in the diagnosis and treatment of patients.

Reducing the evaluation of medical treatment down to “what works and what doesn't” ignores important questions about individual patient attributes and scientific plausibility. Accordingly, for example, the Obama administration has opened the door to implausible CAM treatments, some of which appear to “work.” Deciding that a treatment “works or doesn't work” is simplistic on many levels, has a subjective dimension and is open to value judgments.

The concern in all this for practicing physicians and their patients, according to Groopman's article, lies in the administration's plan to take over many areas of clinical decision making. At its mildest it would take the form of “libertarian paternalism” where government guideline sanctioned treatments would be “default options” which physicians could opt out of if they could defend their choices as “reasonable.” At its worst it would involve coercion. If it sounds incredible note this from Groopman's article:

Such freedom of choice, however, is not supported by a second key Obama adviser, Peter Orszag, director of the Office of Management and Budget. In June 2008, testifying before Max Baucus's Senate Finance Committee, Orszag—at the time director of the Congressional Budget Office—expressed his belief that behavioral economics should seriously guide the delivery of health care. In subsequent testimony, he made it clear that he does not trust doctors and health administrators to do what is "best" if they do no more than consider treatment guidelines as the "default setting," the procedure that would generally be followed, but with freedom to opt out. Rather, he said,

To alter providers' behavior, it is probably necessary to combine comparative effectiveness research with aggressive promulgation of standards and changes in financial and other incentives. [Emphasis added.]

The word "probably" is gone in the Senate health care bill. Doctors and hospitals that follow "best practices," as defined by government-approved standards, are to receive more money and favorable public assessments. Those who deviate from federal standards would suffer financial loss and would be designated as providers of poor care.

Practicing doctors, Orszag apparently realizes, are not always so intellectually lazy as to accept the default option.

Now this piece was written before the election of Scott P. Brown and that Senate bill is all but dead today. The point remains, though, that Obama and his czars would like more control over our clinical decision making and who knows what they might be able to leverage in the health care provisions of the stimulus package.

Some support for the coercive approach comes from within our own ranks. Hospitalist leader Bob Wachter recently said this (my emphasis):

We simply must find ways to drive the system to produce the highest quality, safest care at the lowest cost, and we need to drag the self-interested laggards along, kicking and screaming if need be. Comparative effectiveness research is the scientific scaffolding for this revolution, so bring it on.

Those self interested laggards, by the way, are us, the rank-and-file of practicing physicians.

Groopman goes to considerable length in his article to expose the fallacy of the simplistic approach of mandating treatments because they “work” as opposed to those that “don't work”, citing recommendations for tight blood sugar control, perioperative beta blockers and all those useless and sometimes harmful CMS core performance measures.

Finally, he discusses the newly promulgated USPSTF mammography guidelines, the latest example of a government sponsored “default option.” Whether that will morph from an option to something more coercive is anyone's guess right now. A recent post by Orac is as nuanced and thorough an analysis of the new guidelines as you're likely to find, illustrating how the complexity of the issue goes far beyond whether screening mammography before age 50 “works” or not. In fact, the guidelines are based more on value judgments than new science, as he points out:

In the meantime, I'm not entirely buying these new recommendations, at least not the argument that they are more "science-based" than the older recommendations when, in actuality, they also arbitrarily decide that screening 1,300 women to save one life is an acceptable cost but screening 1,900 to save a life is not.

Retired Doc in his recent post on the Groopman article characterized the differences between libertarian paternalism and the Orwellian Orszagian coercion model this way (my emphasis):

Basically the LP camp seems to say we ( the experts ) know what is best for you and we will in various not- really- coercive ways gently push you in the right direction. The more traditional progressive view, as exemplified by Orszag, is we know what is right and we,if necessary, will summon the force of law to make you do it.

Who knows where things are headed? Right now the National Guideline Clearing House, an initiative of the AHRQ, is merely a repository of guidelines created by various professional societies. Some government policy leaders, though, would apparently like to replace them with their own guidelines and turn them into mandates. Adopting Dr. Paul Keckley's maxim when he was Vanderbilt's EBM maven---give doctors tools, not rules---I plan to stick with Up to Date, Harrison's, Pub Med and whatever other sources my independent judgment leads me to.

Now, just so no one misunderstands: I am in favor of comparative effectiveness research. I am skeptical and concerned, though, about the agenda behind it.

Image source: screen shot from BBC's 1954 television production of George Orwell's “1984.” Public Domain.


james gaulte said...

So who is the "we" of whom Dr. Wachter speaks?

R. W. Donnell said...

I guess it's the leaders of that revolution he's talking about. And the idea CER is going to be the "scientific scaffolding" for that revolution is interesting to say the least.

But science at its best is evolution more than revolution, and it's been plodding along nicely for decades. Remember the coronary drug project from 1965 which compared four drugs for secondary prevention? Now there's some comparative effectiveness research!

I'm for the advancement of science, but I tend to be more skeptical when the science is driven by an agenda, no matter whose.