8/6/2019 Comparative Effectiveness HA_Oct 2010

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rom e edior-in-cie

Someday historians may gather to discuss cultural and eco-nomic trends in twenty-rst-century America. Tey will de-scribe an anomalous reality: a

country living in what purported to be ascientic age, save for such tendencies

as almost totemic devotion to muchhealth care of little or no proven value.

Let us hope these historians will beable to cite a turning point when thiscult lost its hold on the nation. Perhapsone will unearth a photo of a corner-stone being laid for a new building: P-C O R- I, F MMX.

 As detailed in this thematic issue of  Health Afairs, the institute was createdunder the Aordable Care Act to coordi-nate a major new national push oncomparative eectiveness research. Te

strategy ows from the novel conceptthat before we put patients at huge riskor incur new health care spending, weought to have a reasonably good idea of how well the interventions work—espe-cially compared to diering treatmentsfor the same condition, or (sometimes)for dierent subgroups of patients.

fierce debate

Federal funding in the amount of $1.1billion was allocated for the researchunder the 2009 stimulus law (an ar-ticle by Joshua Benner and colleaguesdetails how the money was spent). Tatspending paved the way for a ercedebate over whether any additionalbacking for the research should be in-corporated into national health reformlegislation enacted this year.

  As John Iglehart describes in thismonth’s Entry Point, Democratic lead-ers largely embraced the idea; many Re-publicans had previously been for it

before they were against it. Meanwhile,fear that the research would lead togovernment rationing of care fueledthe “death panels” fury of summer 2009. More legitimate worries arosefrom those who feared that the researchwould somehow defeat eorts to tailor 

therapies to individuals’ specic char-acteristics or genetic makeup.Such concerns were eventually al-

layed, and the Patient-Centered Out-comes Research Institute was born as aparadoxically nongovernmental insti-tute with a government-appointedboard of directors (names were an-nounced September 23, 2010). Dollarsto carry out the research were to comeprimarily from a tax on health insurers.

Now the “opportunities” side of theresearch ledger is bulging with options.

  As Alan Garber and Harold Sox pointout, the legislation allows the eective-ness of not just individual treatments,but even entire programs to improvepublic health, to be compared. As theInstitute of Medicine heralded, there isunprecedented opportunity “to assistconsumers, clinicians, purchasers andpolicy makers to make informed deci-sions that will improve health care atboth the individual and population lev-

els.” In particular, care could be im-proved for minorities and other groupshistorically left out of much medical re-search, or for those with mental illness-es, as David Shern and colleagues fromMental Health America contend.

Te “challenges” side of the ledger seems equally packed. Papers in this is-sue explore a number of them, includ-ing tactics and methodologies. DaveChokshi et al. discuss such lessons asselecting appropriate “comparators,”lest the deck be stacked when one inter-

 vention is compared inappropriately toanother. Once completed, the researchmust be disseminated in order to

change health care practice. Jerey Lerner et al. thus propose a national pa-tient library of the research for use by clinicians and patients.

the ‘r’ word

Perhaps above all is the challenge im-posed by the health reform law itself,which imposed tight restrictions onwhat could be done with the research toavoid any appearance that it would leadto government rationing. Specically,Medicare was barred from using the re-search to establish cost-eectiveness of 

interventions or from drawing on suchanalyses in deciding whether and how much to pay for a given intervention.

However, solutions are also put for-ward, such as Garber and Sox’s propos-al that “private parties” could performcost-eectiveness analysis based in parton information published by the insti-tute. We can only hope that opponentsof this idea won’t now be inspired topass new legislation blocking o eventhis escape hatch to sanity.

 We sincerely thank the organizationswhose sponsorship and support madethis issue possible: the National Phar-maceutical Council, WellPoint Founda-tion, and Association of American Med-ical Colleges. o state the obvious,these organizations have an interest inadvancing comparative eectivenessresearch, as do all Americans. As is cus-tomary, the sponsors had no role in theselection or editing of articles, and allcontent was peer-reviewed. n

doi: 10.1377/hlthaff.2010.0900

Comparative Efectiveness:Coherent Health Care At Last?

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