Plans seek more comparative health information: Insurers, payers expect data on value of health treatments will save money, improve care

June 1, 2007

Economists and health experts on all sides are clamoring for more evidence on how medical products and procedures compare in safety, efficacy and cost. Legislative proposals before Congress include a range of initiatives to spur more comparative effectiveness (CE) research.

Economists and health experts on all sides are clamoring for more evidence on how medical products and procedures compare in safety, efficacy and cost. Legislative proposals before Congress include a range of initiatives to spur more comparative effectiveness (CE) research.

Insurers and MCOs similarly seek more comparative information to help patients and clinicians make value-based healthcare decisions. The BlueCross BlueShield Assn. proposes that insurers, payers and public health programs provide $500 million a year to support an independent institute to develop CE information. BCBSA wants Congress to authorize the new entity and to require Medicare and other public health programs to consider such research in making coverage and reimbursement decisions. In addition, providers that follow guidelines developed by the CE institute would gain a safe-harbor from non-economic and punitive damages as part of malpractice reform.

CONTROLLING COSTS

The stated goal of these proposals is to ensure appropriate and high-quality patient care. But the underlying aim is to contain healthcare spending. U.S. outlays for healthcare are skyrocketing, and insurers and government health programs are looking to adopt evidence-based medicine and pay-for-performance models to gain some control over outlays. These remedies require more credible information on what works best for treating patients and what new technologies merit higher price tags.

The debate has accelerated since health policy expert Gail Wilensky of Project HOPE made the case for a multi-billion-dollar Center for Comparative Effectiveness in an article published by Health Affairs in November 2006. She envisions a quasi-public entity that would assess alternative therapies and procedures to inform payer decision making, but would not address costs directly.

MedPAC avoids any specific mention of costs or prices in its CE research recommendation. In discussing the issue at its April meeting, though, panel members acknowledged that CE analysis will be used by insurers and government health programs in reimbursement decisions.

The danger is that effectiveness studies also could be used to limit coverage and treatment options to low-cost products. And additional research requirements for pharmaceutical manufacturers could be costly and discourage new drug development.

Yet, the comparative research approach may be preferable to price controls in the guise of government negotiations for the Medicare drug benefit, coverage denials and limits on access to new technologies. A new CE center could centralize and coordinate public and private CE research efforts, ensure quality analysis and oversee dissemination of vetted results to providers, payers and patients.

Jill Wechsler, a veteran reporter, has been covering Capitol Hill since 1994.