Powerful forces continue to propel our national health care costs upward. One such force is unrealistic expectations. We often expect too much from our health care system. We find it easier to depend on the healers rather than do the things that we know will prevent illness. The number of people reporting serious illness episodes has increased over 150% from 1920 to 1980. This attitude is firmly entrenched and has helped lead to an explosion in health care costs.
In addition, a further factor in the increasing health cost dilemma is the fact that health care costs and utilization differ markedly across the country. For example, one study showed that in the last 2 years of life patients used 10.6 hospital patient days in Bend, Oregon compared to 34.9 days in New York City. In the last 6 months of life patients visited a doctor 15.5 times in Ogden, Utah and 59.2 times in Los Angeles. Further, a recent study in the Journal of Health Affairs found that more intense and costly care does not necessarily provide better quality treatment. How can we address this dilemma and develop better decision making tools for patients and providers? On what basis can we change our reimbursement systems from payment for expensive procedures and services to payment for value and wellness?
One tool that addresses these issues is Comparative Effectiveness Research (CER. Our current Federal budget allocates over one billion dollars to fund CER. The goal of CER is to provide tools for better decision making by patients and providers. The Institute of Medicine clearly explains the concept. The medical field is founded upon an inherent trust placed by the patient in their doctor. Often the doctor and the patient must make decisions in the absence of complete information. CER offers the opportunity to address these challenges by demonstrating the effectiveness of one strategy over the other for a certain condition. This results in the ability of patients and doctors to make smart health decisions founded on sound scientific evidence.
It has been suggested in a report by the Congressional Budget Office that by using the results of CER, Medicare spending–and perhaps all health care spending in the country–could be cut by about 30%. Other estimates offered are much less; however, most everyone agrees that by utilizing CER we could reduce unnecessary health care costs and utilization significantly. There is a growing trend toward high deductible health insurance that is coupled with a Health Care Savings Account. These patients would be an ideal user of CER information as a tool to control costs and become wise shoppers for health care services.
A common criticism of CER is that it will become a back door leading to rationing health care. The out of control spending on Medicare and the health care system in general would be a driving force that would promote it. CER without proper safeguards of patient and physician involvement should not be the final basis for determining proper medical treatment.
The ethical issues of any limits placed on healthcare services are very complex. Pope John Paul II in his “Evangelum Vitae” stated that we must never give in to the culture of death. However he also stated that “life does not require using every available means to postpone death but what is always wrong is direct and intentional killing.” John Frame, a professor at Reformed Theological Seminary in Orlando, Florida writes that “we can let a patient die when we lack in some way the resources to save his life, whether they are time, technology, or skill.
The ethical use of CER will be necessary if we are to retain the excellent attributes of our present system. Current reform proposals are being hotly debated in Washington. Our complex health care system is already scheduled for significant change. Any utilization of CER must maintain the central role of the physician and insure that the patient is at the heart of health care. We must insure that CER will not become politicized and that a permanent bureaucracy not be allowed to prescribe patient care. Unfortunately we are dependent on the stated objectives of CER by Washington. Hopefully there will be an improvement in the ability to match words and actions. Life is full of trade-offs and hopefully CER will be a positive tool that will become available to all of us as we approach the end of life here on earth.