The backlash was “definitely a sobering experience for those of us who have been pushing comparative effectiveness,” said Gail Wilensky, PhD, senior fellow at Project Hope, an international health education organization. “It suggests that timing is important, as is not being tone-deaf to the political environment and to explain why you’re going against conventional wisdom or previous recommendations.”
Explore this issue:April 2010
Another concern is that public and private payers will use the findings to limit coverage and reimbursement for medical options deemed less effective. Under the ARRA, public payers are barred from using the evidence for payment or coverage decisions, Dr. Conway said. In addition, the health reform bill states the findings should not be construed as coverage or reimbursement mandates.
But Dr. Conway offered this caveat: “We’ll never be able to control every private payer. But to take it a step farther and say we shouldn’t even be producing this information is a false argument.” Proponents argue that insurers often make decisions now mainly based on cost. At least comparative effectiveness findings would allow plans to make clinically informed choices, Dr. Conway said.
Dr. Wilensky said insurers should not stop covering or paying for approved interventions. Using the findings to create value-based coverage and reimbursement would be more sensible, she said. “You reimburse more and you have lower co-payments for the stuff that really seems to have a beneficial effect, and the rest you can make more expensive,” she said.
The assumption often is that newer, more expensive treatments will be shown to be less effective than older ones. According to the medical association letter: “While comparative effectiveness research may identify some low-cost treatments that yield better outcomes than high-cost alternatives, the reverse is also true: Comparative effectiveness research analyses might persuade cost-conscious payers, purchasers and patients that an expensive new medical innovation offers better value than current therapies,”
Putting It into Practice
Although agencies are already using the new funding, it might take years for the findings to be completed. However, a major focus is to quickly and clearly disseminate the evidence to practicing physicians, Dr. Conway said, adding that when findings are released, medical associations will have to decide whether to create evidence-based practice guidelines.
Geri Aston is a health policy writer based in Chicago.