DrRich’s valued colleague R. W. Donnell, who writes Notes From Dr. RW, has responded to a recent post in which DrRich bravely came out in favor of Comparative Effectiveness Research, even at the cost (DrRich asserted) of alienating the majority of the more conservative-leaning components of his readership.
Dr. RW, noting DrRich’s claim that conservatives have laid out a formal policy of opposition to CER, says:
“OK, stop. Where are these people, conservatives or those of any ilk, who have taken a position against CER? Dr. Rich cites groups who are skeptical and very concerned about the new political agenda for CER, not CER itself.”
Dr. RW is, of course, correct. Research that compares the relative effectiveness of medical procedures or treatments is not only inherently a very good thing, but also is a form of research that has a long and proud history. Healthcare would be an even more dire activity than it is today without the large body of research that guides physicians in making recommendations to their patients when more than one option is available. So yes, comparative effectiveness research is obviously a valuable and time-honored endeavor, and for anyone (conservatives or anyone else) to come out against it would be akin to coming out against babies, or bunnies. (Though, as one whose effort to grow vegetables has been severely challenged each year by a pride of aggressive rabbits, DrRich, as it happens, is indeed against bunnies.)
So, to reiterate, neither conservatives nor anyone else are really against comparative effectiveness research, just as Dr. RW asserts.
What they are against is Comparative Effectiveness Research. They are against a new government bureaucracy that sets the CER agenda, whose stated goal is to create a more efficient and less expensive healthcare system, and that will have the authority to determine what gets reimbursed and what doesn’t.
Dr. RW has made it plain that he is not confused about the following point, but many are: There is a difference between comparative effectiveness research (whose unambiguous goal is to compare the clinical effectiveness among different treatment options, so as to offer physicians objective guidance in making clinical decisions, and which is as unassailable as babies and bunnies), and Comparative Effectiveness Research (which is to be operated by a new government bureaucracy, whose agenda regarding what kind of effectiveness is actually to be compared is intentionally ambiguous).
The ambiguity of CER (as compared to cer) was made clear recently when Peter Orszag testified on behalf of the administration before the Senate Finance Committee. When queried by skeptical Republicans on the ultimate goal of the proposed CER board, Mr. Orszag was evasive. Specifically, when asked by Senator Kyle (R-Arizona) whether the CER board would be empowered to make decisions on which medical services will be reimbursed, Mr. Orszag finally replied, “Not at this point,” a reply which did not alleviate the suspicions of the minority party.
To state the ambiguity more plainly, it is clear that while the CER board will mainly be concerned about comparing “cost effectiveness” (which is the only way they can potentially achieve their main goal of reducing healthcare costs), the only kind of effectiveness they are willing to discuss publicly is “clinical effectiveness.”
This studied ambiguity allows proponents of the new government plan to paint opponents of the CER board as being against the “babies and bunnies” form of comparative effectiveness research, and thus reveal those nay-sayers as being beneath contempt, unworthy of anyone’s attention. Meanwhile they will be free to advance their real “cost effectiveness” agenda.
DrRich agrees with conservatives that this kind of deceptive ambiguity is indeed contemptible. But really, it is no more contemptible than the thousands of other forms of covert healthcare rationing we see all around us. (Covert rationing inherently relies on ambiguity – saying we’re doing one thing while all the time we’re doing another.)
Having tried to clarify this distinction between cer and CER, DrRich will now repeat that his prior post was not merely to express support for the “babies and bunnies” variety. As Dr. RW points out, everybody is in favor of that kind of comparative effectiveness research.
Rather – and this is where he further jeopardizes his continued tolerance by his conservative readers – DrRich is offering his support to the other kind of CER, the kind described in the stimulus bill, which (though the administration will not say it publicly) will undoubtedly use comparative effectiveness research to perform cost effectiveness calculations, then coerce physicians, through one form of federal subterfuge and intimidation or another, to employ the least expensive therapies. The government bureaucrats, just as they are doing today but with less muscle, will shout “quality” while enforcing “cost.”
DrRich supports this kind of CER not because it is a good thing – it decidedly is not. He supports it because here is a form of covert rationing that will at last effect everyone, and will be so blatant that after a time even us Americans will no longer be able to ignore it, try as we might. DrRich believes that relatively soon, we would notice that here is a cadre of unelected bureaucrats rationing our healthcare – determining which of us lives and dies – through some opaque process, and lying to us about it the whole time. He believes this to be the pathway most likely to get the American people to finally face the fact of healthcare rationing, and to goad them into an open debate on the best and least harmful way to accomplish it.
Go ahead. Call him a cock-eyed optimist.
*This blog post was originally published at The Covert Rationing Blog*