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Monthly Archives: March 2010

CER vs. CEA

When President Obama and others have gone before the American people to promote their health reform agenda, they’ve often over-simplified an important set of tools available to us in health services research. The President has said things like “If you just bought a new car, and then find out that your neighbor bought the exact same car for $5,000 less, you’d want to know how he did it.” and “If there’s a blue pill and a red pill, and both work about the same, but the blue pill costs half as much as the red pill, which one should we be paying for?”

Critics have jumped on these scenarios and talk of comparative effectiveness panels have been overshadowed by talk of death panels that want to pull the plug on Grandma. Neither side has it quite right. In fact, there are two ways to make comparisons between two treatments: One is as if only effectiveness matters and the other is as if both effectiveness and cost matter.

The first approach is comparative effectiveness research (CER). If there are two treatments for a particular condition, which one works best? CER is designed to answer that question. After all, if the purpose of health care is to restore health, we certainly want to be using the most effective treatments. This is equally true if we’re talking about a 50% efficacy rate compared to an 80% efficacy rate or if we’re talking about a 90% efficacy rate compared to a 90.5% efficacy rate. Why settle for less than the best?

Well, economists have the answer to that question: Because the gains in efficacy may cost too much. If the procedure with 50% efficacy costs $1,500 we might well be willing to pay $6,000 for the procedure with 80% efficacy. However, if the procedure with 90% efficacy cost $1,500 it is doubtful that we’d be willing to pay another $4,500 for the 0.5% bump in efficacy. When the calculations include not only efficacy but also cost, we are no longer conducting CER but cost effectiveness analysis (CEA). It’s a way of calculating a unit-price–kind of like when you’re at the grocery store and see two differently-sized boxes of the same cereal. Obviously, the larger box costs more, but often, the price per ounce has decreased, making it the better deal.

Of course, we as patients–especially with most of us insulated from costs by insurance–seldom make such calculations. We are much more concerned with getting the most efficacious treatment available that is also covered by our insurance. We don’t comparison shop for health care. Sometimes–like in an emergency–we can’t. Other times–like for an annual physical–we don’t have access to the data.

Moreover, a number of questions are raised by CEA that don’t arise with CER. How much are we willing to pay for an additional gain in efficacy? For an additional year of life? For an additional year of high-quality life? There are estimates of this sort of thing, but the problem is that the “price points” surely vary for everyone depending on how they perceive their current quality of life, how old they are, how much money they have, and so on. But, at some point, all the care you can get stops being worth the money you’re having to throw at it. This isn’t rationing any more than you are rationing when you decide which brand of beer to buy at the store. Both sides owe it to us to paint a clear picture of CER and CEA and the roles of both going forward, with or without health reform.

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Posted by on March 23, 2010 in Uncategorized

 

Tenacious Ds: A Health Reform Victory

I almost don’t know where to begin. Should I write about the long history of failed health reform efforts that just witnessed its streak come to an end? Should I continue trying to explain the legislation so that people will have a better understanding of what it does and does not contain? Should I focus on the legislative process, the merits of reconciliation, and the obstructionist tactics of the right on this issue? I’ve written about all of this, and I will again, but not today. No, today I just want to say one simple thing: Sometimes politicians set aside personal interests to do what is right for the country. When they do so, they ought to be applauded for it.

I watched and recorded more C-SPAN yesterday than I ever thought possible. At times it got pretty heated on the floor of the House–almost resembling the British Parliament. That’s understandable given the level of energy and resultant emotion that everyone had vested in this debate. That’s why there were angry mobs rallying outside of the Capitol. That’s why Rep. John Boehner set aside decorum repeatedly and shouted “Hell No!” during his closing remarks before the vote. That’s why the House Gallery had to be quieted on numerous occasions when applause broke out.

http://specials.washingtonpost.com/mv/embed/?title=Boehner%20raises%20voice%20in%20the%20House&stillURL=http%3A%2F%2Fwww.washingtonpost.com%2Fwp-dyn%2Fcontent%2Fphoto%2F2010%2F03%2F21%2FPH2010032103834.jpg&flvURL=%2Fmedia%2F2010%2F03212010-10v&width=480&height=270&autoStart=false&clickThru=http%3A%2F%2Fwww.washingtonpost.com%2Fwp-dyn%2Fcontent%2Fvideo%2F2010%2F03%2F21%2FVI2010032103812.html

As the President has said many times, this wasn’t good politics, it was good policy. This is a mid-term election year, and the stakes are high for many members of Congress. Yet enough of them were able to summon the courage of their convictions and do the right thing–setting aside the possibility that they may lose their bid for re-election. That selflessness is, in my opinion, one of the hallmarks of great leadership.

http://specials.washingtonpost.com/mv/embed/?title=Obama%20reacts%20to%20House%20vote&stillURL=http%3A%2F%2Fwww.washingtonpost.com%2Fwp-dyn%2Fcontent%2Fphoto%2F2010%2F03%2F22%2FPH2010032203970.jpg&flvURL=%2Fmedia%2F2010%2F03222010-1v&width=480&height=270&autoStart=false&clickThru=http%3A%2F%2Fwww.washingtonpost.com%2Fwp-dyn%2Fcontent%2Fvideo%2F2010%2F03%2F22%2FVI2010032203961.html

For the more than a year that this debate has gone on, there are any number of points in the process at which the push for reform could have died. Indeed, if health reform were your grandmother, it should be noted that special interests and the GOP were working feverishly to pull the plug on her. Many times the news was less than optimistic. In fact, it was often downright cynical. We had been down this path before, and we had gotten lost, never making it to our destination. We had become conditioned to cave in at the first sign of opposition. But not this Congress and this Administration. They pushed forward. When the media reported that health care reform was dead, when the topic took a backseat in the news to talk of the economy, our elected officials were working harder than ever to finish the race set before them. Last night, the tenacious Democrats crossed the finish line.

Now, this is but one leg of the race, one step further down the path. This legislation surely won’t fix all that ails the U.S. health care system, but it certainly moves us along in the right direction and demonstrates that it is possible to legislate improvements to our system–holding the door open for future Presidents and Congresses to pick up the torch of reform and carry it forward.

Like Congress, my work is not done. In the days, months, and years ahead I will use my blog to discuss issues surrounding implementation of these reforms, ongoing developments in the areas of health policy and health services research, and any new reform efforts that may arise. For now, though, I just want to say to Congress: “Well done.” And I want to provide you with some links to some great resources, including these on how the votes were cast and what health reform means for you (here’s a second similar resource).

Obviously, there will be much, much more to come.

 
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Posted by on March 22, 2010 in Uncategorized

 

Health Care Reform and The Economy

Chris Hayes of The Nation chats with the Washington Post‘s Ezra Klein about the realities of health care reform and what it would mean for the economy. This is good stuff, as usual.

http://s3.amazonaws.com/thenation/audio/player.swf

 
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Posted by on March 22, 2010 in Uncategorized

 

You Want The Charts? You Can’t Handle The Charts!

I had scheduled this to post tomorrow. Obviously, it’s already outdated. The charts are still cool, though, so I wanted you to see them.

Actually, these two charts make the world a little bit easier to understand, I think. The first one takes a look at the historical uses of reconciliation. It provides an overview of the bill, its net effect on the deficit, which party controlled the Presidency, House, and Senate, the outcome of the final vote, and some background on the issue. It is well worth a look. Notice especially the three big red arrows indicating that bills passed during reconciliation actually increased the deficit. The party of small government manages to run up the debt? No wonder the Tea Party Patriots have broken from the ranks of the GOP.

The second chart takes a look at the Democratic members of the House who originally voted against the health care reform bill back in November. This is important, because the big question now–assuming that reconciliation is the way forward–is will there be enough votes in the House to pass the Senate’s bill? Will some of the “nays” change to “yeas”? This chart, which shows margin of victory in the last election, the Presidential election winner’s percentage of the vote in the district in 2008, and other characteristics, demonstrates that this isn’t just about health reform. For certain members of Congress, it’s about getting re-elected in 2010.

 
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Posted by on March 22, 2010 in Uncategorized

 

BREAKING: Bart Stupak & Friends Reach Compromise

Well, it looks like the guess work is over. President Obama will sign an executive order (full text here) to clarify that no federal funds shall be used to fund abortions. That has Rep. Bart Stupak and his coalition of anywhere between 6 and 12 House members happy enough to vote in favor of the Senate’s health care reform legislation. That means that Nancy Pelosi’s likely got the magic number of votes (216) needed to send the health care bill to the President’s desk for his signature as early as tonight. That means that–while you won’t necessarily feel it–you will wake up on Monday morning in a country that has finally acted after several long decades to make its health care system work for its citizens.

I wanted to post this now–because I found it exciting–but I don’t want to put the cart before the horse, so I’m not going to say anything else until the votes are counted later tonight. I would urge you, however, to send me your comments–good or bad–and I’ll plan to turn them into a post that I’ll put up over at the Huffington Post tomorrow.

 
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Posted by on March 21, 2010 in Uncategorized

 

A Host of Fun Facts

It’s Friday. Work and school have me quite busy. I don’t have much time to write a new blog post. You want to read some interesting new material. How about we compromise on this one and I present you with a variety of “fun facts” I’ve collected over the last couple of weeks? Read them at your leisure:

Rep. Bart Stupak (D-MI) opposes the Senate’s version of the health reform bill, arguing that its restrictions on federal funding of abortion aren’t as strict as the restrictions he introduced into the House bill. He also claims to have about a dozen other members of Congress on his side–the Stupak 12–who he says will vote no on the Senate’s health reform bill despite having originally voted for the House bill. If his claim is legitimate, we’ve got a bit of a problem. Fortunately, as this post shows, there’s good reason to doubt his numbers.

After all their disparaging remarks about the reconciliation process, it looks like the GOP is giving up on that argument. Perhaps that’s because they know that the historical uses of reconciliation don’t cast the party in a favorable light. Or, perhaps it’s because if reform does manage to get passed, Republicans are already making plans to repeal it after what they hope is a return to power following the 2010 elections.

At the same time, some are speculating that while the right campaigns on a promise to repeal health reform, the left will campaign on a promise to implement the public insurance option, which has effectively been abandoned for now.

But the most fun fact of all? Sarah Palin and her family used to travel across the border to Canada to get health care. Apparently, the “socialized medicine” she openly critiques is good enough for her, but not for the rest of the country.

 
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Posted by on March 19, 2010 in Uncategorized

 

Health Reform Would Set Deficit Record

The long-awaited CBO report is finally out and it’s good news. The compromise legislation would be the largest deficit reduction of any bill Congress has adopted since 1993 according to a story in the New York Times. It’s projected to reduce the deficit by $138 billion over ten years and by as much as $1.2 trillion over 20 years. If you’re one of those people who actually like to read things without the media filter, the CBO report is here.

 
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Posted by on March 18, 2010 in Uncategorized

 
 
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