My primary care doctor spent half of our 20 minute appointment complaining that she has to waste too much of her time with each patient entering data into the computer. She became a doctor, she sighed, because she wanted to “help people live better, fuller, longer lives not to serve a machine”.
She needs-to-get-over-it! The computer in the exam room can facilitate scientific research that will help people live better, fuller, longer lives! That is, unless the science is co-opted by the government through the Institute for Patient-Centric Outcomes and the Independent Payment Advisory Board (IPAB) in 2015.
To illustrate the science – Kaiser has been trying to increase the number of patients who undergo routine colon cancer screening for 20 years. About 10 years ago, they migrated all of their patient health records onto a single, standardized computerized platform. I know, I wrote the business rationale.
For the first time, Kaiser could readily identify their entire 50 to 75 year old patient population and track test results over a decade. Researchers compared the effectiveness of screening colonoscopy to less invasive testing methods, both to determine diagnostic reliability and patient compliance. At the end of the decade, they had doubled the rate of patient participation and saved more lives through early detection.
This research technique is known as comparative effectiveness. Comparative effectiveness compares outcomes first on the basis of quality and compassionate care. Then, all things being equal, it considers comparative cost. In Kaiser’s case, it turned out the cost savings were significant.
It’s a technique well suited to Kaiser. Their patient population is large (8.9 million patients), diverse, stable, and in some cases includes a patient history over multiple decades – sometimes from pre-natal to birth through adulthood. This will allow future comparisons across generations to determine the impact of environment versus genetics, for example.
Now enter Obamacare. During the debate over the ACA some staffers apparently heard the term “comparative effectiveness research”, from an insurance industry lobbyist. Here, they thought, was a panacea for cost control and cost reduction.
Congress authorized $3.5 billion dollars to establish a Patient-Centered Outcomes Research Institute – under Centers for Medicare and Medicaid Services (CMS). The Institute is already identifying, funding and collecting comparative effectiveness studies from health care institutions around the country with the intent to establish national standardized diagnostic and treatment protocols.
Standardized and patient-centric – now there’s an oxymoron! Human beings are not shrink-wrappable! For example, standard basal temperature of a healthy adult is 98.6 degrees. But I am a healthy adult whose basal temperature is 97.6 – always has been. Under a standard reimbursement protocol, an emergency room might not be reimbursed for treating me for fever until I reached the standard of 103, instead of the more appropriate 102, even if that resulted in harm to me.
The same legislation established the Independent Payment Advisory Board (IPAB). The board, unelected and unaccountable, will begin to make Medicare coverage decisions in 2015 justified by comparative effectiveness studies collected by the Institute. Medicare coverage decisions are usually quickly adopted by Medicaid and private insurers.
Congress stipulated that cost should not be considered in determining the relative effectiveness of test or treatment options. But I’m a bit too familiar with the difference between legislation and regulatory interpretation to take that stipulation seriously. ACA was an 1100 page bill that has spawned 100,000 pages of regulations and they are not done writing, yet!
If better treatment and higher patient satisfaction were REALLY Congress’ altruistic objective, the Institute would have been established as part of the National Institutes for Health (NIH). NIH is “the nation’s medical research agency – supporting scientific studies that turn discovery into health”. The NIH already regularly sponsors comparative research with private health care systems – i.e. Kaiser, Mayo etc. At best, the Patient-Centric Institute is a $3.5 billion duplication of effort. At worst, parallel efforts may lead to conflicting results adding confusion where clarity is the objective.
In the America I imagine, our national objective would be to reduce the cost of health care through unbiased scientific research — extending the limits of our knowledge instead of constraining the study to comparisons between known options. Sometimes research generates new drugs, new therapies, and new medical devices and sometimes it proves that less treatment is more helpful. The last is, in fact, the most patient-centric of medical choices.
Meanwhile, I am starting to worry about what penalty the IPAB will assess for being allergic to aspirin. It is, according to many comparative research studies, the best, low-cost preventative miracle drug against cancer, heart disease and arthritis – just not for me!
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Photo Credit: Health Allianze