health care cost monitor act 1 – the hastings center

8/14/2019 Health Care Cost Monitor Act 1 The Hastings Center

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Health Care Reform: The Beginning of

the End, or the End of the Beginning?

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aniel Calahand, Health Care Cost Monitor

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Contents

Comparative Effectiveness

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Comparative Eectiveness: One Size Doesn't Fit All Peter Ubel, M.D. 1

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Comparative Effectiveness:

One Size Doesn't Fit All

eter el, ..

JULY 1, 2009 Does comparative eectiveness research orce one size ts all decision-

making? Not necessarily. With the right data, comparative eectiveness research can

improve medical care by splitting patients into relevant groups, rather than lumping them

all together.

COMPARATIVE EFFECTIVENESS


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Comparative Eectiveness: One Size Doesn't Fit All Peter Ubel, M.D. 2

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Peter A. Ubel M.D. is director o the Center or Behavioral and

Decision Sciences at the University o Michigan. He is author o

P L: Wy (MIT

Press, 2000) and Mk Md: Wy N-

Odd Ed Wy M (Har-

vard Business Press, 2009). His blog is www.PeterUbel.com .

[email protected]; 734-615-8591.


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How Comparative Eectiveness Research Can Save Money Susan Bartlett Foote 3

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How Comparative Effectiveness

Research Can Save Money

usan Bartlett Foote

JULY 7, 2009 The prospect o using comparative eectiveness inormation, especially in

relation to costs, causes concern in the eyes o those who would lose prots. In reality however,

an embrace o more research may reduce waste and unnecessary care.

http://blogs.consumerreports.org/health/2009/03/comparative-effectiveness-better-care-lower-costs.htmlhttp://www.newamerica.net/blog/new-health-dialogue/2009/quality-comparative-effectiveness-whats-debate-11624http://jhppl.dukejournals.org/cgi/content/abstract/27/5/707http://jhppl.dukejournals.org/cgi/content/abstract/27/5/707http://www.newamerica.net/blog/new-health-dialogue/2009/quality-comparative-effectiveness-whats-debate-11624http://blogs.consumerreports.org/health/2009/03/comparative-effectiveness-better-care-lower-costs.html


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How Comparative Eectiveness Research Can Save Money Susan Bartlett Foote 4

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Susan Bartlett Foote, J.D., is a proessor in the Division o

Health Policy and Management at the University o Minne-

sota. Her research ocuses on the inuences o public policies

o health care services, with an emphasis on innovation in

medical technology. She is the author o Managing the Medical

Arms Race: Innovation and Public Policy in the Medical Device

Industry. She served on the CMS Medicare Coverage Advisory

Committee rom 2004 to 2006. [email protected]; 651-336-7995.


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Comparative Eectiveness Research and the Doctor-Patient Relationship Eric Cassell, M.D. 6

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Eric Cassell, M.D., is an internist who practiced medicine or

almost 40 years. He is an Emeritus Proessor at Weill Medical

o Cornell University and an Adjunct Proessor o Medicine o

McGill Universitys Faculty o Medicine. He is a Master o the

American College o Medicine and a member o the Institute o

Medicine. He has written extensively about doctoring, the care

o the dying, suering, and moral problems in medicine. eric@

ericcassell.com, 917 365 5639.
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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Virtual Colonoscopy: A Window into the Challenges o Health Care Reorm Ruth Faden and Sean Tunis 9

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Virtual Colonoscopy: A Window into

the Challenges of Health Care Reform

Ruth Faen an d ean Tunis

AUGUST 6, 2009 Medicares controversial decision in 2009 not to cover virtual colonoscopy

underscores the tremendous challenges involved in interpreting medical research ndings.

Although they examined the same evidence, dierent review groups emphasized dierent

risks and other scientic inormation. Such choices are judgments, not acts, and this is true

o all such clinical policy decisions, no matter how evidence-based.

http://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298http://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298http://www.bcbs.com/blueresources/tec/press/ct-colonography-virtual.htmlhttp://www.bcbs.com/blueresources/tec/press/ct-colonography-virtual.htmlhttp://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298http://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298


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Virtual Colonoscopy: A Window into the Challenges o Health Care Reorm Ruth Faden and Sean Tunis 10

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Ruth Faden, PhD., M.P.H., directs the Johns Hopkins Berman

Institute o Bioethics. [email protected], 443-287-0413. Sean

Tunis, M.D., directs the Center or Medical Technology Policy,

a nonprot organization in Baltimore and is the ormer Chie

Medical Ocer or [email protected], 410-

963-8873.


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Cancer and Comparative Eectiveness Research John Geyman, M.D. 11

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Effectiveness Research

ohn eman, ..

AUGUST 25, 2009 It is no longer unusual or chemotherapy to cost more than $100,000 a

year. Oncologists are oten reluctant to be the bad guy by denying patients the option o

a treatment. Comparative eectiveness research may help determine which treatments are

truly valuable, controlling costs and improving quality.



18/84

Cancer and Comparative Eectiveness Research John Geyman, M.D. 12

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John Geyman, M.D. is a amily physician and proessor emeri-

tus o amily medicine at University o Washington. He is the

author o several books, including G and

D N : Wy I Idy

Dy, d W M I. [email protected].

edu; 360-378-6264.
http://theoncologist.alphamedpress.org/cgi/content/full/11/2/90http://theoncologist.alphamedpress.org/cgi/content/full/11/2/90


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Competition and Health Care Costs Joseph White 13

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Competition and Health Care Costs

oseph hite

MAY 29, 2009 Advocates or competition in health care are rarely deterred by the evidence

that its measures have never worked. While there should still be room or virtuous

competition in health care reorm, we must realize and accept that, at present, competition in

the health care system takes largely unconstructive orms.

COMPETITION


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http://finance.senate.gov/Stuart%20Altman.pdfhttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://finance.senate.gov/Stuart%20Altman.pdf


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Joseph White is Chair o Political Science, Luxenberg Family

Proessor o Public Policy, and Director o the Center or Policy

Studies at Case Western Reserve University. His most recent

book is : Wy G S Sy

d Md Sv .joseph.white@

case.edu; 216-514-8337


22/84

Competition: The Public Plan's Fatal Flaw Daniel Callahan 16

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Competition: The Public

Plan's Fatal Flaw

aniel Callahan

JUNE 19, 2009 The greatest aw o the proposed public plan is its embrace o competition

as the central mechanism or cost control. History suggests that competition as a whole is

an ineective way to run a health care system. Real reorm lies in price controls and other

regulatory strategies.

COMPETITION
http://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=ushttp://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=ushttp://voices.washingtonpost.com/44/2009/06/08/senate_republicans_send_obama.htmlhttp://voices.washingtonpost.com/44/2009/06/08/senate_republicans_send_obama.htmlhttp://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=ushttp://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=us


23/84

Competition: The Public Plan's Fatal Flaw Daniel Callahan 17

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by .

Daniel Callahan is editor o the M.
http://www.politico.com/news/stories/0609/23755.htmlhttp://www.newamerica.net/publications/policy/modest_proposal_competing_public_health_planhttp://www.newamerica.net/publications/policy/modest_proposal_competing_public_health_planhttp://www.politico.com/news/stories/0609/23755.html


24/84

Deusing the Health Care Time Bomb: Lessons rom the 1990s Alain Enthoven 18

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We need ve actions:

1. Cost conscious consumer choice o health plan

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2. Organize the market or competition at the consumer level.

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lack o that choice blocks the growth o ecient health care de-

livery systems.

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Defusing the Health Care Time Bomb:

Lessons from the 1990s

Alain nthoen

AUGUST 18, 2009 While the concept o managed competition rom the 1990s ell out o

avor, the ather o managed competition describes ways that it can be updated to improve

consumer choice and create incentives or more ecient health care delivery. Health care

would be o high quality, but premiums would be aordable.

COMPETITION


25/84

Deusing the Health Care Time Bomb: Lessons rom the 1990s Alain Enthoven 19

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integrated high perormance systems.Pd Ob y, -

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4. Address other barriers to an ecient aordable health care.

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-bd y.

Alain Enthoven, Ph.D., is the Marriner S. Eccles Proessor o

Public and Private Management, emeritus, at Stanord Univer-

sity and a core aculty member at Stanords Center or Health

Policy and Center or Primary Care and Outcomes Research.

He is known as the ather o managed competition. He is a

member o the Institute o Medicine o the National Academy o

Sciences. [email protected]; 650-723-0641.


26/84

Health Care Reorm: The Role o Hospitals and the Need or Equity Blair L. Sadler 20

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Health Care Reform: The Role of

Hospitals and the Need for Equity

Blair . aler

JULY 13, 2009 A hospital reimbursement system in which every procedure and test

generates a acilities ee and a doctor ee is in need o reorm that rewards quality instead o

quantity. But reorm also needs to level the playing eld so that saety net hospitals dont bear

a disproportionate nancial burden.

HOSPITALS
http://www.kaiserhealthnews.org/Stories/2009/July/08/hospital-woes.aspxhttp://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrailhttp://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrailhttp://www.kaiserhealthnews.org/Stories/2009/July/08/hospital-woes.aspx


27/84


28/84

Fixing Medicare Muriel Gillick, M.D. 22

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Fixing Medicare

uriel illic, ..

MAY 22, 2009 Eective Medicare reorm requires implementing a coordinated, integrated

approach to the management o chronic disease. While Medicare is ailing to cover a variety

o services that are critically important or older patients, it is simultaneously paying or an

enormous amount o care that is useless and in many cases even harmul.

MEDICARE


29/84

Fixing Medicare Muriel Gillick, M.D. 23

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1997 16.1 2005, y jdz

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qy .

Muriel R. Gillick, MD, is a geriatrician and palliative care

physician at Harvard Vanguard Medical Associates in Bostonand a Proessor o Ambulatory Care and Prevention at Harvard

Medical School. Her most recent book is D :

P Y, E L, d O D -

. [email protected]; 617-509-9977.


30/84

Cost Trends in Heart Disease, End Stage Renal Disease, Cancer, and Metabolic Syndrome Polo Black Golde 24

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Cost Trends in Heart Disease, End Stage Renal

Disease, Cancer, and Metabolic Syndrome

olo Blac ole

MAY 22, 2009 The Medicare Trust Fund is expected to be insolvent in eight years at the

current rate o spending, as a result o more enrollees living longer and in worse health. Four

leading medical conditions underline this trend.

MEDICARE


31/84

Cost Trends in Heart Disease, End Stage Renal Disease, Cancer, and Metabolic Syndrome Polo Black Golde 25

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Polo Black Golde is a research assistant at The Hastings Center


32/84

Lie-Extending Treatments or the Oldest Patients Sharon Kauman 26

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Life-Extending Treatments for

the Oldest Patients

haron auman

MAY 26, 2009 The routine use o innovative lie-prolonging treatments has led to an

increase in interventions perormed on people in their 80s and older. I we do not better dene

medical success and the best treatment plans in an aging society, we may nd that we are

wasting money at the end o lie.

MEDICARE


33/84


y y .

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34/84


v v y

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Complicating medical success

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Sharon R. Kauman, PhD, is proessor o medical anthropol-

ogy at the University o Caliornia, San Francisco. Her current

primary research ocus is on the impact o medical technique on

individuals in an aging society. Her most recent book is d

D: S Ed L;

mailto:[email protected]:[email protected]


35/84


36/84

Is Death Optional? Muriel Gillick, M.D. 30

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Muriel R. Gillick, MD, is a geriatrician and palliative care

physician at Harvard Vanguard Medical Associates in Boston

and a Proessor o Ambulatory Care and Prevention at Harvard

Medical School. Her most recent book is D :

P Y, E L, d O D -

. [email protected]; 617-509-9977.


37/84

Death by Rationing? Not Here Susan Gilbert 31

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Death by Rationing?

Not Here

usan ilert

JULY 9, 2009 A congregation o nuns in Rochester, N.Y., who live their last days with

excellent palliative care in a supportive and stimulating environment, oten choose not to

have lie-extending treatments. A geriatrician who cares or the nuns told The New York

Times that they have better deaths than any I have seen. There is reason to believe that their

care be replicated outside the convent.

MEDICARE
http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://newoldage.blogs.nytimes.com/http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3482&blogid=87870http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?category=Medicare&blogid=87870http://www.nytimes.com/interactive/2009/07/08/us/20090708_SISTERS/index.htmlhttp://www.nytimes.com/interactive/2009/07/08/us/20090708_SISTERS/index.htmlhttp://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?category=Medicare&blogid=87870http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3482&blogid=87870http://newoldage.blogs.nytimes.com/http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1


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39/84


40/84

Reducing Regional Variations in Spending Anthony Mareo 34

b $420 b. d kd b

dv v

d, vy b v- , y v .

D dy ,

vy-dd y vd.

dvy by

d by d d . O

, d k d v dy

k f bk. v, d,

My vd , xd

dy y d, d v k

y b d .

v d b d; y

y y -dv v. -

d qy d qy d y,

y y, d d. df

y .

Anthony Mareo is a ourth year medical student at Yale.An-

[email protected].
http://healthaffairs.org/blog/2009/06/17/geography-and-the-keys-to-health-care-reform/mailto:[email protected]:[email protected]:[email protected]:[email protected]://healthaffairs.org/blog/2009/06/17/geography-and-the-keys-to-health-care-reform/


41/84


42/84


43/84

Cost Control in Europe: Ineciency is Unethical Richard B. Saltman 37

I bv E -

xd vy

Ud S. qk y d q

Oz E d Dv-

(OED) E y v -

d .

yy b d

bdy E y,

by yk

.

yd d , v,

b x-dd d dd

E y U.S. y,

qy E d x-

d . Lk y

E, -

, y dd dd

, qy d v-

y . x, d y dy y.

d y

G Md ,

Sd v y d

v dd N

d d W. I , d

k d

b d d

d -

y d .

Y ky q b d

d, d y d

dv d. , Sd

, d W E yk v

, d y d dv

d y .

I Sd, dvdy-d

y S y

d y 300 k ($40) y.

b y d x-

b Sd ( 9.1 -

GDP 2005) d U.K. (8.3 GDP

2005) dd q ,

.

Additional examples include:

I U.K., d v v; , -

v vv -

v d, d ( ,

y) y d .

I Sd, 70 d d by x-

by d bdy y

d v vd.

b dd d dd

d, y v v b x d

Cost Control in Europe:

Inefficiency is Unethical

Richar B. altman

JUNE 10, 2009 Many o the dierences between the U.S. and European countries in health

care spending are the result o stricter budgetary constraints and oversight. Can measures

like government regulation o insurance premiums and coverage be implemented here?

OTHER COUNTRIES


44/84


dd x x y

.

I y E , dv -y y y y v.

v v b vd x-

dd y d vv v,

ky d xd (q -

k d U.S., Md).

I I, E-y -

y, d b d d d

dd v bk v, k

d d by d dvy 70 -

b. N d d b ddd

dq d (d by x) dy v-

b.

v dbk dv. y dfy k

d v, d, x-dd

y, y b

vy ( y , U.K.)

v d.

y d y y d

zd U.S. y dd, d y

y v E-

. (D E-

y E Obvy.)

, b , -

v f. Ny E v -

y d b xd v,

y b dy .

, v k dd

d y xd. y , , y

d (d E -

, y) d

v v. v

vy b d y -

k y f d -

v.

y

E.

1. Regulating private insurers

Germany: P by y

v k .

Switzerland: y b

k dy b v, d

d v v qd -d

d, d bd q.

2. Expanding Primary Care Services

U.K. and Finland: v vv , v y

y v.

U.K.: dy v y

; y d

k xv . S-

d d W, v, v

y d y .

Finland: G d

, k y k -

v.

Denmark: GP d x db

7,500 D k (b $1,400)

d 1,000 k (b $180) vd y.

3. Supporting Home Care Services and InormalCaregivers

Germany: Gv y ,

b v y b d vd -

.

Sweden, Denmark, and Norway: v v

b y d -

y y b.

Sweden: Pvd , dv

, d v d

d k .

Netherlands: bd k- , d by

, dy , v d, k v

, d v v v bd b b-

vd v .

y dd d -

v dd v

d xv . I , d-

b y y d

dd xv v, ,

dy, d xv v b.

b y d by

j d .

d y -

dby xv y U.S.

y bd d

d by d-d b ( d

) d v (K P) vd.

b E v
http://www.euro.who.int/document/e87303.pdfhttp://www.euro.who.int/document/e87303.pdf


45/84


v, y f v-

y: dy d

y v xd- y .

yk j dv

y E y

d dv y -

d vd.

v v

bk y dd E -

d. I v dy -

y d , yd , , d -

, y d y W E M

, b d y-

k x U.S.

M dy, v -v W y d-

d by M d/ 27

E E U Pdy

Sby Sy, d P

My 11 d 12. xd, E yk d-

d k y v d

f.

Sk d d M Dz

(d WO Of E) , -

, fy . Eqy,

d d by dd v-

d d d

d dd b v -

.

D k U.S., y

b dd d d

E x, y v

, Szd. vy

vvd d vy xd b , d y x

b y x.

, xdd dy,

d 7 10 GDP

k y d b b b

d v bd

y. M U.S., d 16

GDP , by dv

dd b xd-

, y v y xd v

.

I d vy d - d d E-y y -

b dq v b

dy -

z yk U. S.

Richard B. Saltman is Proessor o Health Policy and Manage-

ment at the Emory University School o Public Health. He is

coounder o the European Observatory on Health Systems and

Policies in Brussels and is currently head o the Atlanta hub He

has published 16 books and over 130 articles and book chapters

on a wide variety o health policy topics, particularly on the

European health care systems. He has twice won the European

Healthcare Management Associations annual prize or the

best publication in health policy and management in Europe.



46/84

Cost Control in Canada: Complaints o Underunding Theodore Marmor 40

v y b d d

Ud S 2009 d

v 1993-4. -

y db , x Wall Street

Journals y, ky . dy

Gy, d, , Ud K-

d, b-

vy d y .

S, k d y vd -

v v d-

b. d 10 v -

d d y v

y ddb, -, -y.

k / Sd y 1960,

x d.

d d Md d

y xdd : v

k 1957 1961 v dy d-

d . Lk, y y b-

1967 d 1971.

d Md b d y v d dd, b d -

d dd y d

d-1990 v v bd k

d xd y. dy,

Md -

y d y v

v, 2005 S d-

d v v Qb

v . I , v

d b v

by dd v.

d v

y y k U.S. My y

y vy kb d d -

d z. W dd

v x, d ( ). d

d bd v

; dv, , q d ; d

y dby (10 d

v U.S. 16 17 ) b.

b b d U.S

b d d d y

y y y. U.S. d

y d .

Iy, d k U.S. y

d d y b U.S. Md d

, y y

v d d dy d

y. d y

b y, U.S. Szd vd .

Udd b , d

y

d b.

d bd d x d

.

y d bv,

q by. G d v y d

k v y d. d -

Cost Control in Canada:

Complaints of Underfunding

Theoore armor

JUNE 12, 2009 For over three and a hal decades, Canada has provided health insurance

coverage to its entire population while delivering decent care. Canada continues to control

costs exceedingly better than the U.S. by sticking to a budget.

OTHER COUNTRIES


47/84

Cost Control in Canada: Complaints o Underunding Theodore Marmor 41

d vy b ,

y v, y.

, I d , b - d d b -

d b bd. S d bv

vy d b b y v -

v , k, qzd v-

bd. v U.S. x -

y bj vy

bd d .

dd, U.S. k y

vd dv v k d d.

y y, y d bd x

v b v, -

by , x , -

- (ddb, -, -y), d

d d d.

b d: -

z v ( MO PPO d byd) d

xd. I b 1970, U.S.

d d y GNP

d (y 7 ). y y ,

U.S. d 50 d

d d, , v -

--k d.

v v bv b

y d q d. O x

d b d

.

My d b k

d y dd

ddv . I d

Md , y bkd. W b-

d d Md d y

v v y, bd d -

b v d d d .

W d, d E-

y d Nd , dd

v . d S zd

W E d

v d

U.S. ( d d

b v xd, q

v U.S. dd.)

M z b

Nd, y x -

y .W k v x, I d

yd by d b xd

x d v . d,

U.K., Sd, Nd, Gy x bd-

q b d d . I

d bd x , -

v d/ x b d. v

y.

N x d

d. W dv d d -

d . , I

k, v d b

U.S. 2009.

Theodore Marmor, PhD, is Proessor Emeritus o public policy

and management and o political science at Yale School o

Management. His books include P Md;

[email protected], 203-376-7739.
http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3486&blogid=87870mailto:[email protected]:[email protected]://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3486&blogid=87870


48/84

How Nice is NICE? A Conversation with Anthony Culyer The Editors 42

N I Ex (NIE)

d vy -v

d v d d d dv. U

y, Ud Kd y y k

, b , d , -

z, b, d d, y NIE

y v . W kd y J.

y, PD, d Dv -

NIE, d y d dd -

.

What is the role o technology assessment in the U.K.health care system?

dy k, U.K. b -

d y. O d v

d v -

bd v b .

, d N Sv (NS), d x-; vd b -

v d NS.

y y y v

v db vd

y k. W vd f b d-

, db d v-

d-d dk, d d d vd

vb d.

k NIE dv vy y.

b y dd d.

dd 1950, dq d

b d y, -

dd d d k -

dd d d b

k.

How does NICE t into technology assessment?

by , NS

k d k dd q k

NIE y NS v d-

b . NIE z. I , -

v, j .

NIE y d y d

, by b, d bd d v

b bqy vd y xv d d

kd, d dy.

xz b NS vd vv, d, v

v, d y, dy y

.

-v NIE y

xd qy-dd y

d 20,000 30,000 (b

$26,000 $36,000) b dd.

d b qy (, x-

, v ) jdd by v

How Nice is NICE? A Conversation

with Anthony Culyer

The itors

JUNE 22, 2009 Britains National Institute or Clinical Excellence (NICE) assesses the

relative health benets o particular procedures. Creating incentives to invent new products

that are cost eective will lead to better health and more cost containment, argues Culyer,

chairman o NICEs Research and Development Committee.

OTHER COUNTRIES


49/84


. v d x d

b dd.

What kind o authority does NICE have?

NIE b y. I guidance,

b d b d, d

k d d d dv. d

q, d d -

qy , d

, -d, d

y ky b v.

L d vd mustk y

y dd by NIE vb -

qd by y. I , NIE b

dyphysicians v d. d NIE d b, -

y , y x-

by dv d,

, d d b

d d vy.

What is the role o QALYs in decision-making?

NIE d v Qy-dj-

d L-Y (EQ -5D), y

b NIE dvy k -

b y b d d b

dd b bk d y -

v .

QLY , . I y d

-v .

QLY d b-

d, d

d dvdd by QLY d

d d , -v

y dd. -

--QLY d , d y

xd , d

b v d.

I y , v, QLY vb dq x. -

d v dvy y

QLY d

d NIE y -d jd

d.

--QLY b d bb

v d. I d jd,

d, y q d x

.

Is NICE a threat to physicians reedom to practice? Is it athreat to industry?

NIE d j : d.

x

dv d d b d

k.

b y b vd b -

.

W d ky NIE

k-k d d d

dy ky .

, d x b y

-bd d y y

d v. I

, d, v v d -v, b d

v v both b and

.

Are recent attacks on some NICE decisions evidence osome deep unrest?

d . W d d -

z v , NIE k

bd v, .

I vb b . I

vb v jd d

, v b d x

vy y , b. NIE d b

v d b v b

v vy .

y b b d

I b NIE d

y bd d-k d

y dy. , v, d

b b d

vb d y v dd

v. b b k b -

y d dd vb

.

Are any important reorms in the NICE program likely?

NIE d d

d kdy v

k d v . -

xd NIE k dv d.

b b k d

vd b, k, d, bd.


50/84


y d NIE

y b y

vv - d , d

qy . NIE k

y -

d, b , d, -b -

v d, b qy

vd b.

b

NIE . Sd d-

d? W b d? O

d? W b dv

d d v -

vd by

k?

v x

kd d x d. W -

v x , v

dvd v k -

. I NIE k y ! NIE y

b y f.

v NIE

d b d b ddd

y d y

.

Anthony J. Culyer, PhD, is the Ontario Research Chair in

Health Policy & System Design at the University o Toronto

and proessor o economics at the University o York, [email protected]; 011-1904-433762.


51/84

Comparative Eectiveness and Rationing: Lessons rom NICE Mark Heland and Louise Russell 45

vy d v 2009 d-

d $1.1 b v v -

d d d

d v.

y v v d

vby d . Wall Street Journal

d d v v

. G W dd -

v v d dy dv

v d . I

d y v d .

y ,

N I d

Ex (NIE), v v d

-v y dv N

Sv d b vdd -

v. : b q d

b NIE. I , y

d d b - d v v .

d 1947, N Sv (NS)

d vy vy 50 y b

NIE bd, y by bd -

v y d k . bd -

d, NS y zd d vy-

vybdy. I , d

NIE d y v d-

d, db y by v.

W NIE d y vb

NS vy d y. NIE

b b NS bd. O

d .

W NIE d 1999, dd d

dd q b

d . D. G L, b NIE d d

Dy Exv d O Of NS

Evd, dbd y: W -

vd d by ---

d d, vd x d

b dd, v

y . I dv y

ddz v

NS vd d y y d

W d d

y.

y d

dbd Ud S dy, d q v

y 10 y .

dy d dd v -

, y y v, y v dvd

, d b v , Dvd L-

d d y The New York Times.

Mv, d v d by

, D , d v

Md d Mdd y.

Comparative Effectiveness and

Rationing: Lessons from NICE

ar Helan an d ouise Russell

JUNE 22, 2009 American attempts at comparative eectiveness research have prompted

charges o rationing. However, a ree ow o inormation about benets, harms, and costs

through publicly unded comparative eectiveness research could improve health care in the

U.S. Examining how Britains NICE uses this research suggests potential benets.

OTHER COUNTRIES
http://online.wsj.com/article/SB123318915075926757.htmlhttp://online.wsj.com/article/SB123318915075926757.htmlhttp://www.washingtonpost.com/wp-dyn/content/article/2009/01/28/AR2009012802939.htmlhttp://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&scp=1&sq=David%20Leonhardt%20and%20rationing&st=csehttp://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&scp=1&sq=David%20Leonhardt%20and%20rationing&st=csehttp://www.washingtonpost.com/wp-dyn/content/article/2009/01/28/AR2009012802939.htmlhttp://online.wsj.com/article/SB123318915075926757.html


52/84

Comparative Eectiveness and Rationing: Lessons rom NICE Mark Heland and Louise Russell 46

y , b b d x b

d y v b d v y b ,

d v d v, v dd. v d NIE -

d vk -v.

y v d .

, y , NIE y y, NS

bd vd vy y.

Sd, NIE b b. ,

, y , d kd

k xy vd, , d d-

d d. Ov , d b y-

b , d d

x d qy d v d-

k.

y, x, y d v b -v, NIE vd -

dd y d d

. NIE

y d , b

d bd xy.

, NIE y d d

b ky b. y d

y v d v -

dd v

dy vb.

NIE d , xd NS

bd, bd v d d v

k y v vd

b y. , dd

-v y , kdd

d d q d ,

, NS y y -

d y

.

I U.S., xd bd ,

v v

y , b d by

dvd d y, d

d y d . N

y, , Db 2007 d O- d v v

d by .

d NIE, U.S. v v

d v-

d. , b k v dd d d d y,

k d d

by b d v.

d d dv, x, -

d d d D d-

d d

q b k b d

d . d d kd -

, d v d v, d

k d v b

d k d b

.

Sx, d Annals o Internal Medicine, y d ky dd

Py 2009 I Md : b

y y dy--

d . b y d

d b d

vy d k k d d. W

y NI-d

x. v, NI d -

dy.

I , U.S. k v v

y b . I b

dd b b,

d . W , by dd -

v v d v

U.S. by d d bz dd,

v b k b .

Mark Heland, M.D., is editor-in-chie o the journal Md

D Mk, a sta physician at the Portland V.A. Medi-

cal Center, and a proessor o medicine at Oregon Health & Sci-

ences University, where he directs the Oregon Evidence-based

Practice Center. [email protected], 503-494-4277. Louise Rus-

sell, PhD, is an economist and research proessor in the Insti-

tute or Health and a proessor in the Department o Economicsat Rutgers University. She is an associate editor o the journal.

http://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtmlhttp://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtmlhttp://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtmlhttp://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtml


53/84

NICER in the U.S.? Steven Pearson, M.D. 47

dy I d y y yy v y

NIE, I y dy v NIE

d d k -

U.K. dbd -

d dd d d

y y, b

d.

xd, d b -

d by NIE, v d

d, N Sv

-v d d d. S.

W y y, v, yb-

, d v k NIE d

v --- q

. I I

d , y b NIE U.K., b

v b b b d

v v

b b d Ud S.Ud: Why would anyone in their right mind wish to

deny such drugs to people with a lung condition in the rst place?

Madness. It was probably all to do with money like it is when peo-

ple with cancer are denied drugs to help prolong their lie. Seems

that there is always enough money to ensure that smacked up

drug addicts get their methadone though. To sum up: Put yoursel

in a situation requiring ree drugs and youve got it. Be unortu-

nate to suer through no ault o your own and youll have to ght

or your right to lie saving drugs. What a Country eh?

Yky: Well said, Utdlass, I cannot agree with you

more.

W d, I k, -

dy y b

d . NIE, , -

b , d-

v -bkd jd, , d d,

y y, d

--k , d

d d v d dy

d d ,

d y y

q b y

bd y d jd d

d . v.

d, , z , 10 y

NIE d. I , y y db y

y, NIE v d d

E y b kd yy b- xd v d k -

, k vd-bd d

b . Y, NIE y y v.

y d k y-

y, d qy dd y

y, b, ddy,

d d by d v v

d dd, NIE k k

W, , v dy y

NICER in the U.S.?

teen earson, ..

JUNE 26, 2009 Although NICE has been labeled un-American, the U.S. may end up with

an entity like it to oversee the comparative eectiveness research mandated by the stimulus

legislation. However, such a body in the U.S. would not in act be NICER, because it would

ail to take cost into account, make clinical recommendations, or do little more than dissem-

inate technical reports.

OTHER COUNTRIES


54/84


Ud S.

d b d b d

NIE v , , d d dvd -

v y b .

y d E,

dy k k d dy, d

d bb

dy. d d d

dv .

W b ? Y d bd v-

b y bdd? I j .

d NIE j d b

jd -. v, y

NIE vv Ed , d v-

y d b d, U.S. b bk .

L k-

y d b

d b x

qy

y d d k b, ,

d . v ky

y NIE? d

NIE ky d d

v v y?

d d, d y, I

U.S. y N I v E-

v (NIE).

, q d

NIE y E y b

d d. NIE b d

k d, -

d d v

by b d v y.

S kd NIE d

d , d

d , b y dvd y jd-

. b d bz vd

d z d b d b d-

NIE v x b.M ky, v, NIE dv y

vd v v,

Ud S Pvv Sv k (USPS)

d y vv v.

y d y d k vd v

b d ; d b

y k d y, v-

d-bd , d v v-bd

d .

j NIE b d

NIE -v d d-

d jd v. -v, v by v , -

j y $1.1 b v

v b

k y dd

b.

v dd by NIE -

d dv v d vd

, y v d vd .

Db v v NIE

U.S. v d, d, d-

y d -v d y b

d by -v d d v

d y -v d - dy v xv v (v v

d d b d).

O d db y

v dv, d ,

, d v y z,

Py. kd -

v d b d d

d d.

Id, v, d b d-

vd d v -

v qv; d,

y, dd vy qb

v d b dd bj-

v, dd vd d y

dv d . I -

d, -v NIE d

b q: I ?

M xd y bv

v ky vv y

d NIE b-

bd () b .

d b b

b NIE k -

v d d v, b

b k k db.D x v ky b

v v. W

, NIE v

, U.S. y v

y d vd

qy d .

NIE Ed v d y y

NIE U.S., b y,

d d, yb z :


55/84


v y v b db-

b d , k

y v y;d d d

E dd 10 y y zd

y d k d .

Steven Pearson, M.D., M.Sc. is ounder and president o the In-

stitute or Clinical and Economic Review (ICER), an academic

group at Massachusetts General Hospital in Boston that o-

cuses on health technology appraisal policy. He spent a year at

NICE as a Senior Visiting Fellow on an Atlantic Fellowship in

Public Policy, and then served as a special advisor at Medicare

and as a senior ellow at Americas Health Insurance Plans.



56/84


57/84

Doctor Choice Abroad Richard B. Saltman 51

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d (d y). b

b d by y y d,y E (d by

y).

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k .

Specialist care

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U.K., Dk, Sd, d, Ny, S, d

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y ( )

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U.K., Nd, d Gy), y b

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y dd.

dy k d x ( v GP), db E

y b x -

b v d dd

dvd v. W d

v d d j-

y, d d -

v vy d y.

Richard B. Saltman is Proessor o Health Policy and Manage-

ment at the Emory University School o Public Health. He is

coounder o the European Observatory on Health Systems

and Policies in Brussels and is currently head o the Atlanta

hub He has published 16 books and over 130 articles and book

chapters on a wide variety o health policy topics, particularly

on the European health care systems. His new volume on Nordic

Health Care Systems, co-edited with Jon Magnussen o Norway

and Karsten Vrangbaek o Denmark, will be published later this

month by McGraw-Hill [email protected];

404-727-8743.


58/84


59/84

Speaking Truth to Evasion Daniel Callahan 53

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vd. I d k y b d b jd. W bv

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d k y b

v b, z d vd

ky , d. Oy by k-

dy, y, d v,

d .

Daniel Callahan is editor o the M.


60/84

Ending the Cost Insanity: Some First Steps Henry J. Aaron 54

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.

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dd , d

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d.

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U. S. v d

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.

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z, d k

v. d d

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z y d .

d b d

d y k

W d y k

z d y d-

Ending the Cost Insanity:

Some First Steps

Henr . Aaron

MAY 20, 2009 Fragmentation o payers, cost insulation, and an excess supply o services

without research into their eectiveness have made our current health care nancing system

as immune as possible to cost discipline. How can talk o controlling health care spending

move beyond just talk, and little else?

POLITICS


61/84


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d .

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d b. U.S.

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v d.

v -

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, y v y

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db W d b whether

y , d d how d . d


62/84


I k -y dv -bd

d y b , d

, v y. f? I db . Exd

v , d jy -

, v y v

d. ,

y v, bby v-

, , vd by bd .

bd k y

kd x, S Sy. O d

v d

bd . y y

d by , I bv

k d j

k, d . W bd b

y, k d vd v d .

Henry J. Aaron is the Bruce and Virginia MacLaury Senior

Fellow at The Brookings Institution. His areas o research

include the reorm o health care nancing and public health

care systems such as Medicare and Medicaid. This article was

adapted rom Aarons remarks or the twentieth anniversary o

Harvard Medical Schools Department o Health Care Policy.



63/84

Cost Control: Where Does it Stand? Daniel Callahan 57

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d

health care cost monitor act 1 – the hastings center

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