Stimulus Bill Moves America Closer to Practicing Evidence-Based Medicine

As part of the stimulus package passed by Congress last Friday (H.R. 1: American Recovery and Reinvestment Act of 2009), the US will be ramping up efforts to encourage evidence-based medicine. This is a very good thing.

Specifically (from The New York Times):

The $787 billion economic stimulus bill approved by Congress will, for the first time, provide substantial amounts of money for the federal government to compare the effectiveness of different treatments for the same illness.

Under the legislation, researchers will receive $1.1 billion to compare drugs, medical devices, surgery and other ways of treating specific conditions. The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.

The program responds to a growing concern that doctors have little or no solid evidence of the value of many treatments. Supporters of the research hope it will eventually save money by discouraging the use of costly, ineffective treatments.

The soaring cost of health care is widely seen as a problem for the economy. Spending on health care totaled $2.2 trillion, or 16 percent of the nation's gross domestic product, in 2007, and the Congressional Budget Office estimates that, without any changes in federal law, it will rise to 25 percent of the G.D.P. in 2025.

Just to put things into context, although $1.1 billion sounds like a lot of money, this is only 0.14 % of the bill, and the potential long-term savings are many times that.

So, we're going to spend a little bit of money to make sure our medical treatments are actually effective, thus saving us a lot of money (and wasted effort) down the road. Who would have a problem with that?

As Congress translated the idea into legislation, it became a lightning rod for pharmaceutical and medical-device lobbyists, who fear the findings will be used by insurers or the government to deny coverage for more expensive treatments and, thus, to ration care.

In addition, Republican lawmakers and conservative commentators complained that the legislation would allow the federal government to intrude in a person's health care by enforcing clinical guidelines and treatment protocols.

So, enforcing good medical practice is a bad thing? Really?

I'm not even going to attempt to link to every reactionary right-wing screed against this provision, but you can read about them--and why they're totally off base--at various other locations. And, if you're feeling really brave, you can try to actually wade through the full text of the bill. Good luck with that. Suffice it to say, though, that nothing in this bill gives any credence to the idea that the bill will lead to the US rationing health care.

Of course, the question of whether the US should take cost into account in determining the effectiveness of a medical treatment is a totally different issue. Despite some people's gut reaction to the contrary, the only rational answer to that is of course "yes". The government most certainly should not pay $100,000 to provide a patient with a brand spankin' new drug offering dubious benefits at the expense of treating many more with well-validated therapies. And, if that sounds heartless, just keep in mind that the buck has to stop somewhere. The government (and health insurers) won't be able to keep up with exponentially rising health costs without making some tough decisions somewhere.

For such a system to work, though, somebody has to make the tough decisions. And, of course, these decisions need to be made scientifically, requiring an organization capable of synthesizing the needed information from available studies and commissioning its own when necessary. The prototypical example is the United Kingdom's National Institute for Health and Clinical Excellence (NICE), which you can read more about in a recent feature The Times did on it back in December. It's not surprising that the UK boasts this achievement, given that the centralized nature of the NHS paves the way for such an organization to operate with maximum efficacy.

NICE really is evidence-based medicine to the extreme, and if the idea makes some Americans uneasy, don't worry: I wouldn't expect anything so efficient to emerge within the American health care system anytime soon. And, that's a shame, because by drawing a line in the sand, NICE has been able to negotiate much reduced prices for some drugs and has--needless to say--saved UK taxpayers a bunch of money.

Of course, NICE has problems, and those problems, like almost any other issue with the NHS, stems from chronic underfunding. Remember, the US spends the most per capita on health care out of any nation in the world ($6,700 per person per year, which is more than twice what the UK spends), and we don't even have universal health care. If the UK spent that much, there would be many fewer tough decisions. And, in such an evidence-based-medicine-friendly environment, that money would go much further than it does in the US.