There are, however, two provisions that employers and the medical professionals feel strongly about: establishing a Center for Comparative Effectiveness, where researchers would study how well various medical approaches work in treating a single ailment; and putting more emphasis on primary care through the creation of patient-centered medical homes, a type of primary care that emphasizes—and pays doctors more for—the management of preventive and chronic illnesses.
These separate programs, though, have not been free from attack in recent weeks by opponents of the current health care reform proposals, who say they will lead to rationing. The “r” word, a bogeyman that has flowed from the lips of critics, has successfully tapped into deep-seated fears among Americans and threatens to undermine aspects of health reform that doctors and employers feel are key to improving medical care.
Now employers, who spent the summer criticizing parts of the reform bill they didn’t like, are working to defend and promote these proposals. Comparative effectiveness, much more than the medical homes movement, has come under especially harsh criticism, says Helen Darling, president of the National Business Group on Health.
“I don’t think employers understand how serious the threat is,” Darling says. “They should care deeply about this.”
The research is aimed at establishing which treatments are most effective at treating a particular illness. But opponents say the research would eventually be used by bureaucrats to deny people care based on its cost and a person’s age.
“My problem is not with the research,” says Andrew Klavan, a novelist and political writer who has written about the issue. “My problem is with the government using that research to make sole and complete decisions on who gets what, which seems to me is inevitable.”
Republicans have already inserted amendments into the House legislation that would prevent the federal government from using the research to deny people treatment.
“No matter who does the research, you have to prevent that from happening,” says Sylvia Warner, press secretary for Rep. Michael Rogers, R-Michigan. Rogers has added an amendment to the House bill that would explicitly prevent “rationing,” though the word itself has not been clearly defined.
On August 13, the National Business Group on Health, along with the American College of Physicians and other employer and medical groups, sent a letter to congressional leaders expressing their concern that the amendments would prevent employers from using the research to deny covering treatments that were either useless or harmful.
But critics say the research will be used to justify denying care to patients for whom the treatments could prove beneficial, and that a major reason for denying care will ultimately come down to cost. To prove their point, critics cite the British National Health System. In Britain, administrators of the single-payer universal health insurance program use QALYs—or quality adjusted life years—to determine how to cost-effectively use health resources. Using this method, the British National Health Service says on its Web site that if a treatment costs more than £30,000 (about $50,000) per quality adjusted life year, it would not be considered cost-effective. Sometimes that means older and sicker patients can be denied expensive care if the care does little to significantly prolong their life.
But proponents of comparative effectiveness research say they are not promoting the use of the research to deny people lifesaving care because they are too old. The research, they say, is intended to study whether the care, when compared with other interventions for the same condition, works. Today’s method using peer-reviewed journals and testing by agencies such as the Food and Drug administration does not evaluate the merits of one particular treatment over another.
Neil Kirschner, senior associate for regulatory and insurer affairs with the American College of Physicians, says the comparative effectiveness research is about understanding which treatments prescribed by doctors work best.
“The rationing issue is a bogus issue,” Kirschner says. “The primary gain of comparative effectiveness is it helps patients, physicians and payers, like employers, make sure they are getting the best-quality care for their efforts. You’d be surprised how many conditions exist where there are three or four different ways to tackle it. We often don’t have information about the clinical effect, the safety, the side effects, what are the costs involved with different alternatives. This information will help us make better decisions.”
The research is designed to compare the medical effectiveness of various treatments for the same condition. If it is not effective, Darling says, it doesn’t make sense to provide it to the patient, let alone pay for it.
“If something is not medically effective, you wouldn’t even look at cost. It should not be a covered benefit,” she says. On the other hand: “If something is highly effective, no one will not get that in the United States unless they are uninsured.”
The research, Darling says, means employers “will be paying for things that work, which improve life, and we won’t pay for things that don’t work. And that’s not the current mixture that we have.”
The research has already been funded with $1.1 billion in the federal stimulus plan passed this year. The House bill would establish a center within the Department of Health and Human Services “to conduct, support, and synthesize research … in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically.”
For example, comparative effectiveness researchers have explored the most medically effective way to treat patients with stable coronary artery disease, when the arteries that carry blood to the heart are partially blocked. Patients in one group received angioplasty with a metal stent combined with a drug regimen; another group simply received the drugs. “That study found no differences between the two groups of patients in survival rates or the occurrence of heart attacks over a five-year period,” a December 2008 report from the Congressional Budget Office said. Angioplasty, however, did appear to reduce the prevalence of chest pain. The results showed that angioplasty helps relieve symptoms but does not improve survival rates.
Doctors and employers worry, however, that amendments in the bills could make it illegal for employers to design benefits packages that would create incentives for people to choose more effective medical treatments, regardless of the treatment’s cost.
“What we are saying,” Kirschner says, “is it certainly is appropriate to provide incentives for people to get the highest-value care.”
To a much lesser extent, medical homes have also had to overcome an image problem caused by critics, including initially medical specialists, likening it to the managed care HMOs of the 1990s.
“ ‘Medical home’ is this decade’s version of HMO-style insurance, according to the Congressional Budget Office, with a primary-care provider to manage your access to costly services such as visits to specialists and diagnostic tests,” wrote Betsy McCaughey, a health care critic who helped derail health care reform during the Clinton administration, in a Wall Street Journal opinion piece in June.
Indeed, specialists have voiced concern over medical homes. Part of that is based on the perception that primary care doctors in a medical home will act as “gatekeepers”—to use a much maligned word from the HMO days a decade ago—and limit patients’ access to specialists.
“I’ve spent two decades now studying managed care and it’s bad for patients,” says McCaughey, who keeps a three-ring binder with the proposed legislation on her dining room table.
But medical homes are not managed care organizations and primary care doctors have no incentive to limit access to specialists, says Paul Grundy, director of health care technology and strategic initiatives for IBM and president of the patient-centered primary care collaborative, an initiative among employers and doctors to put more money and focus on improving primary care.
“It’s not a gatekeeper model where you are managing not the care of the disease but other doctors,” Grundy says. “That model has been tried and it has failed, and I don’t know why we would want to try it again. It’s not the direction I want to go with my employees.”
Instead, in pilot projects around the country that would be expanded with funding being considered in health care reform bills, doctors are given more money so they can better coordinate the care of chronically ill patients. Electronic health records are used to avoid duplicate testing and to share information with other caregivers, nurse practitioners are made available to counsel patients, and doctors are paid for providing e-mail consultations that make it easier for patients to change dosages or medications.
There is wide support, Grundy says, for giving primary care physicians more money and support to better manage chronic illnesses, which accounted for $277 billion in health care costs in 2007, according to the Milken Institute, which said productivity costs of chronic illness totaled $1.1 trillion that year.
As a result of the initial success of medical homes in improving the health of patients, Grundy says, specialists that once opposed medical homes now support them. Emergency room doctors, for example, who were once concerned about a drop in revenue associated with fewer trips to the ER, now support the medical homes concept because it will mean fewer patients with non-emergencies in the emergency room.
Opposition has had more to do with concern among specialists that paying primary care doctors to more intensively manage the care of their patients will lead to fewer referrals to and decreased revenue for specialists, Grundy says.
“There’s always concern when you touch someone’s revenue,” he says.
Regardless of how health reform turns out, Grundy says employers can change the system by the way they design their benefits.
“What I want to tell employers,” he says, “is that they, in terms of the way they buy their health care, can either be part of the problem or part of the solution.”