A furious storm has blown up over a provision in the economic stimulus package bill—passed in Congress and expected to be signed into law by President Obama on Feb. 17—in what is widely seen as the first political attack on the new administration’s push to fix the health care system.
 
The bill allocates $1.1 billion to “comparative effectiveness research”—a wonkish term used for a process that determines which drugs, devices, surgical procedures and other medical treatments work best for any particular disease or groups of patients, according to the best scientific evidence.
 
Such research is not new but has been carried out in the United States for more than 20 years in public and private programs. The stimulus bill expands funding for it at a national level and coordinates it under a new independent center, to be known as the Federal Coordinating Council for Comparative Effectiveness Research. Its 15 members, half of whom must be physicians or other clinical experts, will be drawn from seven government agencies.
 
Critics of the provision claim that it will bring about cost controls and lead to rationing of care.  Proponents contend that it will allow doctors and patients access to the best evidence when making decisions about care. Moreover, they argue, with 46 million uninsured, American health care is already rationed by the ability to pay.
 
“Ideally, comparative effectiveness means producing reliable, objective comparisons that physicians can share with their patients and help them make an educated decision when there are multiple options,” says Jeffrey P. Harris, M.D., president of the American College of Physicians, which supports the measure. “It allows a physician to sit with the patient and say: Here are the four [treatment] choices; here’s the evidence on which has merit and why; here are the risks associated with each—now, how would you like to proceed?”
 
Based on the best science, comparative effectiveness is not the same as cost-effectiveness—the best bang for the buck.  But controversy has long centered on where the two overlap.  Most experts agree that the United States, which spends far more on health care than any other industrialized nation but has worse medical outcomes, cannot afford health care that is not supported by hard evidence showing its benefit. “Should public funds be used to pay for services of limited or no value?” asked Stuart Altman, professor of national health policy at Brandeis University, at a 2007 conference on comparative research policy. “Unfortunately we are paying for a lot of them.”
 
At the same time, many American experts are wary of European national health systems in which governments use clinical comparative research together with cost-effectiveness as a basis for determining coverage. Economist Gail Wilensky, who formerly headed Medicare and served as a health adviser to President George H.W. Bush, is a leading supporter for the development of a national center for comparative research information. But “I think it is vitally important to keep comparative clinical effectiveness analysis and cost-effectiveness analysis separate from each other,” she wrote in the Annals of Internal Medicine. “Payers, not a national clinical comparativeness program, should do cost-effectiveness analyses—and act on them.”
 
Wilensky and others also argue that a research center must be independent of cost decisions if physicians, patients and health insurers are to view it as a credible source of unbiased information.
 
The stimulus bill reflects that thinking. Its wording specifically separates the federal coordinating council’s research findings from coverage decisions: “Nothing in this section [on coverage rules] shall be construed to permit the Council to mandate coverage, reimbursement or other policies for any public or private payer.”
 
But in recent weeks, reasoned debate and the actual language of the bill have been drowned out by inflammatory distortions voiced by conservative groups and media commentators.  “If the cost of your treatment as a seasoned citizen is deemed by the government to be too expensive based on how much longer you have to live, then you don’t get treated,” Rush Limbaugh said on his radio show.  A Washington Times editorial likened the cost-efficiencies that could derive from comparative effectiveness to euthanasia programs in Hitler’s Germany.
 
“There is absolutely nothing in the stimulus package that will lower the quality of health care or reduce the choices Americans can make about treatment options, and anything said to the contrary is fabricated,” responded Herb Kohl, D-Wis., chairman of the Senate Special Committee on Aging.
 
“Opponents of health reform are now using scare tactics in a misguided attempt to stop progress in its tracks, blocking attempts to fix the broken health care system that is hurting American families and our economy,” says AARP CEO Bill Novelli.

“Opponents—like some drug companies and medical device makers—don’t want this research,” he adds. “They fear it will cut the profits they make on ineffective drugs and equipment. But they won’t tell you that this research could save your life by giving your doctors better information so they can prescribe the best treatments available to you.”
 
The federal Agency for Healthcare Research and Quality, the National Institutes of Health, together with some universities and private insurance companies, have conducted comparative effectiveness research for years. Their findings have increasingly been used as a basis for coverage in public and private health care programs.
 
One example of how this can work is the Washington state Medicaid program, which since 2003 has relied on research from the Drug Effectiveness Review Project (DERP) at Oregon’s Health and Science University in Portland to decide which prescription drugs it will cover under its preferred drug list. DERP analyzes all available scientific literature to compare the safety and effectiveness of different drugs used to treat particular medical conditions, without considering their cost.
 
The committee of doctors and pharmacists that decides Washington’s Medicaid drug list also doesn’t know the cost of any drug before it decides which ones to cover, according to Siri Childs, the program’s director of pharmacy policy. “We do quality first and cost second,” she says. “We pick the drugs based on research that’s been done across the world, literally. The evidence is global, but the decision-making is local.”
 
The approach has saved the state’s Medicaid program millions of dollars, because very often the research shows a very expensive drug to work no better than a less costly one. But if the drug that’s most effective also turns out to be the most expensive, Childs says, it gets onto the list and the state pays for it.
 
The value of comparative effectiveness research, in Childs’ opinion, goes beyond dollars saved for the state. “Everybody has access to this drug list on our website,” she says. “So we’re educating all our citizens—whether they’re prescribers or patients in the Medicaid program or not—on what a safe, cost-effective medication is.”

Patricia Barry is a senior editor at the AARP Bulletin.