The Stimulus Bill includes healthcare cost-effectiveness language that most were not aware of. Recall Dan Hannan's talk against NICE.

Here's an opinion that NICE might not be that not-nice.

http://tinyurl.com/dh5jzk

February 27, 2009

Are We Mature Enough to Make Use of Comparative Effectiveness Research?

By Robert Wachter, MD

Thanks to White House budget director Peter Orszag..., $1.1 billion...into the stimulus...for “comparative effectiveness” research...Our health care system, despite easily being the world’s most expensive, produces (by all objective measures) relatively poor quality care. ... plotting a 2x2 table with costs on one axis and quality on the other, we see a state-by-state Buckshot-o-Gram...

Lots of what we do...is costly and ineffective.We must somehow goose the system to move all providers and patients into the high quality, low cost quadrant...Better evidence about what works would help with such goose-ing.

...one of his procedural specialists told him, “I make my living off unnecessary procedures.” ...

[the legislation has become] a lightening rod for...lobbyists, who fear the findings will be used by insurers or the government ...to ration care. In addition, ...commentators complained that the legislation would allow the federal government to intrude in a person’s health care by enforcing clinical guidelines and treatment protocols.

At this moment, Medicare’s rules – yes, the same Medicare that’s slated to go broke in a decade or so – forbid it to consider cost in its coverage decisions. Rather, its mandate is to cover treatments that are “reasonable and necessary.” ....As Stalin said, “a single death is a tragedy, a million deaths a statistic.” Such is the problem with trying to make rational, evidence-based tradeoffs (that lead some people to not get the care they want) in a media-saturated open society....

A decade ago, Britain’s National Health Service launched NICE, the National Institute for Health and Clinical Excellence. In a recent NEJM article entitled “Saying No Isn’t NICE,” Robert Steinbrook reviewed the “travails” of NICE: Since 2002, National Health Service organizations…have been required to pay for medicines and treatments recommended in NICE “technology appraisals.” The NHS usually does not provide medicines or treatments that are not recommended by NICE… NICE can be viewed as either a heartless rationing agency or an intrepid and impartial messenger for the need to set priorities in health care…

As we look to NICE for a roadmap, it is worth remembering the differing dynamics of a closed, tax-funded system such as the NHS, and the pluralistic, chaotic hodgepodge that is American health care. NICE’s physician-chair told Steinbrook that the Institute had to be fair to all the patients in the National Health Service… If we spend a lot of money on a few patients, we have less money to spend on everyone else. We are not trying to be unkind or cruel. We are trying to look after everybody. NICE, with its 270-member staff and $50M budget, not only reviews whether treatments work, but explicitly analyzes cost-effectiveness...NICE generally does not recommend treatments whose cost per quality-adjusted-life-year is more than about $40,000. According to American health care mythology, our cutoff is $50,000, but... hard to find examples...withheld based on cost-effectiveness... ****Some would say that it might be worth more than $40K, out of our private pocket, to get another quality-adjusted year. It's hard-to-impossible to get private care under some nationalization schemes.**

It remains to be seen…...saying no takes courage – and inevitably provokes outrage.

To me, NICE’s experience shows that rationing based on cost-effectiveness can be done

****Of course, not everything that CAN be done SHOULD be done. MP Hannan thought NICE was bad for patients, doctors, taxpayers and even the bureaucrats who had to make tough choices.***

A second cautionary note: In November, the Times ran an article ... 2002 JAMA hypertension study... found that diuretics, costing pennies a day, worked better than 3 other classes of drugs (ACE inhibitors, calcium channel blockers, and alpha blockers) that cost up to 20 times more. The study....was largely ignored ...Why...? Partly resistance to change, partly new drugs...partly pharmaceutical company lobbying. ...“there’s a lot of magical thinking that [the application of comparative effectiveness studies] will all be science and won’t be politics.”..... buzzword for encoding evidence-based practice was “practice guidelines,” and an agency called the Agency for Health Care and Policy Research (AHCPR) set out to create such guidelines using clinical evidence. Sound familiar? One of the first ...addressed was surgical management of back pain,...The AHCPR panel found virtually no evidence supporting thousands of back surgeries each year, and recommended against them. ...Congress...“zeroed-out” AHCPR’s funding. ... ending the guideline program, re-branding...producing evidence but not recommending practice, and even changing its name to the Agency for Healthcare Research and Quality (AHRQ), ...

We simply must find ways to drive the system to produce the highest quality, safest care at the lowest cost...Comparative effectiveness research is the scientific scaffolding... one person’s “cost-ineffective” procedure may be a ...patient’s last hope for survival...my hope is that we have the brains to produce the right kinds of data, and...to act on it, humanely but responsibly.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together...he coined the term "hospitalist" in an influential 1996 essay in The NEJM.