Listening to the EBM Gurus

I highly recommend the dialogue posted today on the Health Affairs blog. It features Sean Tunis, the former Center for Medicare and Medicaid Services official, and David Eddy, who is a prominent health care consultant, weighing in on evidence-based medicine (EBM).

There's not much disagreement between the two. They both believe that health care costs can be held in check by getting physicians to practice EBM. They both believe that EBM ultimately involves rationing.

What does this mean in layman's language? We can implant stents, defibrillators and do whole body imaging until the cows come home, and it will probably save lives. But many of those advanced technologies don't make economic sense. In terms of the cost per life saved, they are just not worth it. Therefore, it makes sense to ration the use of those services to those who would most likely benefit from them.

There's two missing elements from their discussion.

First, they ignore who created the evidence that goes into "evidence-based medicine." How much rationing is there going to be when the cost-benefit analyses are generated by industry-funded economists sifting through industry-funded clinical trials? Virtually every study I've seen in the literature (admittedly subject to publication bias; few analyses that say a technology simply isn't worth it make it into the literature for obvious reasons) says the new technology is worth every dime the health care system will be asked to pay for it. Only an objective arbiter of the evidence free from all ties to industry can generate information that will be trusted by either physicians or patients.

The second missing discussion was comparative effectiveness analysis. To her credit, Sen. Hillary Clinton, who spoke this morning to the Take Back America conference in Washington, has made setting up a center for studying the value of competing medical approaches a centerpiece of her health care program. She's also highlighted preventive care and better chronic care management (a fancy term for giving wholistic treatment to people with multiple conditions rather than having them see multiple specialists, each of whom makes high fees for treating each condition in isolation).

But, again, there is precious little in the literature outlining the cost-effectiveness of this kind of approach, even though most people intuitively understand that the health care system could probably save money in the long run if it deployed resources into prevention programs that help people live lives that don't lead to chronic illnesses with multiple conditions in the first place. Without a well-funded agency capable of conducting credible comparative effectiveness studies to inform policymaking, the public will never accept the rationing implicit in evidence-based medicine, or spend taxpayer monies on well-designed programs that have the best chance of preventing disease and improving the overall health of the American people.