Wednesday, January 27, 2010

An Excellent Review of the Perils of CCE

Dr Groopman wrote an excellent piece in the New York Review of Books regarding one of my favorite topics, comparative clinical effectiveness. We have been arguing here for more than the past year that CCE is as currently proposed one of the most damning elements of the health care proposals issued from the current Congress.

He commences with the quote from Orszag as follows:

In June 2008, testifying before Max Baucus's Senate Finance Committee, Orszag—at the time director of the Congressional Budget Office—expressed his belief that behavioral economics should seriously guide the delivery of health care. In subsequent testimony, he made it clear that he does not trust doctors and health administrators to do what is "best" if they do no more than consider treatment guidelines as the "default setting," the procedure that would generally be followed, but with freedom to opt out. Rather, he said,
To alter providers' behavior, it is probably necessary to combine comparative effectiveness research with aggressive promulgation of standards and changes in financial and other incentives. [Emphasis added.]

This is a chilling statement in that he seems to be saying that when the Government promulgates a set of clinical guidelines then the Government will take whatever measures necessary to see that the physicians follow those guidelines, now mandates in his view it appears, and if not there will be consequences. That is indeed a chilling effect.

He also uses the reference to Sunstein, the nudge concept, which in essence contends that people will do very little to make personal choices and the Government can select the right one and make them believe by certain exogenous pressures that it is their own choice. Such a subtle mind management reduces rejection on the part of the populace. He states:

Thaler and Sunstein build on behavioral economic research that reveals inertia to be a powerful element in how we act. Most people, they argue, will choose the "default option"—i.e., they will follow a particular course of action that is presented to them instead of making an effort to find an alternative or opt out. Further, they write,

These behavioral tendencies toward doing nothing will be re- inforced if the default option comes with some implicit or explicit suggestion that it represents the normal or even the recommended course of action.

Thus between the heavy hand of Orszag and the manipulative fingers of Sunstein the current Administration wants to get CCE out there as the best was of doing things. As we have said many times before, one should be concerned about some GS 13 outsourcing the next version of Harrison's to the lowest Government contract bidder. The thought is terrifying.

Groopman states:

There is a growing awareness among researchers, including advocates of quality measures, that past efforts to standardize and broadly mandate "best practices" were scientifically misconceived. Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality, the federal body that establishes quality measures, acknowledged that clinical trials yield averages that often do not reflect the "real world" of individual patients, particularly those with multiple medical conditions. Nor do current findings on best practices take into account changes in an illness as it evolves over time. Tight control of blood sugar may help some diabetics, but not others. Such control may be prudent at one stage of the malady and not at a later stage. For years, the standards for treatment of the disease were blind to this clinical reality.

Frankly, not only are these misconceived, as we have argued regarding the PSA results touted almost a year ago, trials which when conceived were worthy, but when completed failed to adjust to the knowledge obtained in the interim, medical knowledge is changing on a daily basis and the communications amongst and between physicians is an ongoing process. It is iterative and collegial, and changing the process to one of officially chronicled results will lead to disaster. Why not just use Osler from say 1926?

Groopman then makes a compelling case for why health care in this country is in many ways the best, the most costly, and the most complex. He states:

Cost-effectiveness is going to be a hard sell to the American public, not only because of the great value placed on each life in the Judeo-Christian tradition, but because the federal government has devoted many hundreds of billions of dollars to bail out Wall Street. To perform mammograms for all American women in their forties costs some $3 billion a year, a pittance compared to the money put into the bank rescue. The Wall Street debacle also made many Americans suspicious of "quants," the math whizzes who developed computer models that in theory accurately assessed value in complex monetary instruments but in fact nearly brought down the worldwide financial system. When a medical statistician says that imposing a limit on mammography is a "no-brainer," people may recall George Tenet's claim that the case for invading Iraq was a "slam-dunk."

Finally Groopman ends with the following:

The care of patients is complex, and choices about treatments involve difficult tradeoffs. That the uncertainties can be erased by mandates from experts is a misconceived panacea, a "focusing illusion." If a bill passes, Cass Sunstein will be central in drawing up the regulations that carry out its principles. Let's hope his thinking prevails.

On this I disagree. As much as Groopman appears to admire the Sunstein approach, as his very article seems to state as its core argument, medical research is an ever changing source of new information. Each patient treated educates the practitioner about the next. Patients themselves are part of the education process. Thus any system, soft or hard in its motivation, mandated from Washington, will in all likelihood be the the detriment of the system, the physician, and the patient.