Full article reprinted from "The Gray Sheet" - October 20, 2008
Democratic presidential candidate Sen. Barack Obama has proposed a comparative effectiveness institute as part of his health care reform plan, but an independent analysis by the Lewin Group suggests that many physicians may not adopt the practices recommended by such a body.
Obama Wants Comparative Effectiveness Institute; Is NICE A Good Model?
Full article reprinted from "The Gray Sheet" - October 20, 2008
Obama says he would establish an institute to guide reviews and research on the comparative effectiveness of alternative diagnostic and therapeutic interventions. The findings would be incorporated into practice guidelines, standards and other evidence-based decision tools for doctors and patients.
Republican presidential candidate Sen. John McCain's health care reform plan does not mention a comparative effectiveness institute.
The Lewin Group, a Falls Church, Va., health care policy research and management consulting firm, found that a great many practice guidelines - including "those recognized as evidence-based" - already exist for health care services, accounting for 20% to 33% of all health care spending for the chronically ill.
However, physician adherence to these guidelines "is quite low," the consulting firm says. It cites a 1999 meta-analysis of studies on adherence to practice guidelines for multiple conditions that found an average adherence of only 55%.
In other examples, Lewin notes a 2004 study of adherence to practice guidelines for managing osteoporosis which showed adherence ranging from 17% to 71%. Also, a 2007 study found that only 25% of physicians complied with guidelines concerning uncomplicated urinary tract infections.
The low adherence to guidelines may be explained in part by a study on the subject by Michael Cabana, reported in the Journal of the American Medical Association in 1999, which found that 57% of physicians were unfamiliar with guidelines and 55% were unaware of guidelines, the Lewin Group said.
Other reasons for non-adherence found by Cabana included physician attitudes, such as lack of agreement and inertia of previous practice.
The consulting group estimated the costs of the comparative effectiveness practices envisioned under the Obama proposal, as well as physicians' adherence to clinical guidelines and the resulting savings in health care costs.
The group assumed the comparative effectiveness program would be funded at $900 million per year, and indexed annually to health care cost growth. In the first year, 2010, the Lewin Group assumed that guidelines would exist for about 30% of chronic care services.
Using historical data from the National Guideline Clearinghouse, Lewin estimated the number of new guidelines would increase by about 2.4% per year, and 75% would address chronic health conditions. The consultants further calculated that 45% of physicians in fee-for-service plans, and 83% in managed care plans, would adhere to the guidelines, based on a 1999 study of adherence rates conducted by Byrd, et al.
With these assumptions, Lewin estimated that physician compliance with evidence-based guidelines would reduce spending by $52 billion for health services by 2019. Program costs over the 10 years would be $11.1 billion, the group said, resulting in net health care savings of $39.9 billion from 2010 to 2019.
Is U.K.'s NICE A Model For The U.S.?
The United Kingdom already has a comparative effectiveness institute in place, operated by Great Britain's National Health Service and known as the National Institute for Health and Clinical Excellence (NICE).
The idea of using NICE as a model for a similar comparative effectiveness institute in this country was debated last month at the AdvaMed 2008 MedTech Conference in Washington, D.C., with most speakers agreeing that NICE would not work within the existing U.S. health care system.
The development of NICE in the U.K. was born of necessity, Duncan Nichol, former chief executive of Britain's National Health Service, told AdvaMed participants Sept. 23. Initially, the health service was operated on a fixed-cost basis by the British government with a budget set at 5% of the gross domestic budget.
"We were spending on technology that costs money," without knowing what health outcomes were being achieved, he said.
In the beginning, the National Health Service used leading clinicians in U.K. teaching hospitals to gather evidence about which technologies were most effective, so as not to waste money on those that were not. NICE eventually evolved as a separate institution within the National Health Service, as a way for the service to conduct health technology assessments and keep costs under control, Nichol explained.
However, Andrew Dillon, NICE's current chief executive, said the institute's approach cannot be exported from one country's health system to another.
The way NICE operates "may be of interest to the U.S. or other countries, but nobody necessarily wants to transplant NICE into the U.S." or anywhere else because "it's plugged into the oddities of the National Health Service in the U.K.," Dillon said.
Nichol said there is a "very conservative clinical practice culture" in the U.K., though he added this is not necessarily a bad thing. "It avoids health professionals barreling ahead to do things that turn out not to be the right thing, perhaps for safety reasons, or maybe just the absence of effectiveness."
In contrast, said Jack Meyer, a principal with Health Management Associates, when advanced medical technology products are introduced in the U.S., "they proliferate throughout the community, to people who are good candidates for them and others who are not."
Meyer pointed to advanced imaging techniques, for which "we do have evidence of overusing," he said. He expressed the widespread suspicion that physicians try to recoup their investment in expensive imaging equipment by ordering excessive testing. "They have a vested interest in running those scans," he said.
Meyer said he could envision an institutional comparative effectiveness arrangement to review newly emerging medical technology, but both the public and private sector would play a role in the institute, unlike the U.K.'s NICE, which is operated by the public health service.
U.K.'s NICE Could Not Work In U.S., Meyer Says
Such an institution would evaluate new medical technology, "not in a yes-or-no decision, so that it could never come to market." Rather, it could determine who the appropriate candidates for the new technology would be, Meyer said.
But a problem with NICE's approach, and the use of its findings in guiding payments under the National Health System, is an "almost obsessive concentration on one yardstick for measuring technology, which is cost that has been quality-adjusted," Meyer said.
"If you do that, things that are relatively low cost and help a lot of people always look good, and things that are heroic and have a small end - rescuing lives - always look bad."
Instead, Meyer championed coverage with evidence development, in which new procedures and technologies could be paid for while evidence is gathered to determine whether and when they really are clinically beneficial and cost effective.
Michael Tanner, a senior fellow with the Cato Institute, argued that NICE "has become quite bureaucratic," and delays the adoption of valuable new medical technology.
Institute Proposed In Senate Bill
A comparative effectiveness institute in the U.S. is already under consideration by Congress.
The Comparative Effectiveness Research Act, introduced July 31 by Senate Finance Committee Chair Max Baucus, D-Mont., and Budget Committee Chair Kent Conrad, D-N.D., would create a private, non-profit Health Care Comparative Effectiveness Research Institute governed by a board including HHS agency directors, device and drug makers, clinicians and patients ("1The Gray Sheet" Aug. 4, 2008 p. 12).
The institute would establish a list of national priorities to study under contract with other entities through systematic reviews and new trials.
Though most likely dead for this year, the legislation could resurface in the next Congress.
- Sue Darcey
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