Acronyms of Denial

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  • 03/12/2008
I am currently "on the road" in Europe with Dr. Frank Lichtenberg of Columbia University. We're speaking on the topic of healthcare technology assessment (HTA). We've already spoken in Brussels (cold and wet) and Rome (sunny and fattening). Today we are in Berlin.

When it comes to health care there are a lot of acronyms. When it comes to cost-containment strategies the main ones are:

HTA: Healthcare Technology Assessment

EBM: Evidence-Based Medicine

CER: Comparative Effectiveness Research

RUM: Rational Use of Medicine

But no matter the acronym, these are all cost-based practices designed to reduce costs and restrict patient care. They are acronyms of denial.

Today, Healthcare Technology Assessment is a short-term, short-sighted, politically-driven policy that results in one-size-fits-all medicine. And while it may provide transitory savings in the short-term, current HTA strategies result in a lower quality of care that result in higher health care costs over time.

Restrictive formularies and health care systems that deny patients access to the right medicine in the right dose at the right time but pay for more invasive and expensive procedures later on have their priorities upside down.

So why is the current HTA model enjoying such wide support? Because it drapes a veil of pseudo-science around the blunt instrument of one-size-fits-all price controls. Consider what Sir Michael Rawlings of NICE said about comparative effectiveness in front of the British House of Commons:

“It is not based on empirical research, there is no empirical research anywhere in the world, it is really based on the collective judgment of the health economists we have approached across the country. It is elusive."

IQWiG in Germany claims that it makes its decisions based on "international standards." But such "standards" do not exist. Nice try though.

HTA, as it is currently designed, places into conflict the short-term budgeting dilemmas of governments elected for relatively short periods of time with the ever-lengthening life spans of its electorate.

HTA is a creature not of health care professionals, but of economists being paid by governments (aka: "payers"). Hardly a group of disinterested academics.

HTA is widely based on the concept of “patient variation,” that the same care should be applied to every patient suffering from the same disease based on evidence derived from RCTs.

In other words, if one medicine is effective for 40% of the target population and another drug within the same therapeutic category if also effective for 40% of the population – but we cannot (because of the design of these RCTs) clinically predict which 40% will respond to either treatment – what kind of evidence is that?

What’s a regulator to do? Their only alternative, as they see it, is to rely on cost-based comparisons. In other words, if two medicines are “equally effective” at 40% -- then they will opt to reimburse the one that costs less.

That isn’t evidence-based medicine. That’s bad medicine.

21st Century HTA models should reflect and measure individual response to treatment based on the combination of genetic, clinical, and demographic factors that indicate what keep people healthy, improve their health, and prevent disease. A rapidly aging society demands a new health care paradigm capable of providing for its needs in the 21st century. Equality of Care must be matched with Quality of Care.

The repercussions of choosing short-term savings over long-term results, of cost-based choices over patient-centric care, of “me-too” medicines over the right treatment for the right patient at the right time – are pernicious to both the public purse and the public health.

As Mark McClellan said, “Looking at a gigantic uniform solution for everything is never going to work.”

We're not at the end of this debate. We're not at the beginning of the end of this debate. But we are at the end of the beginning where at least we can all agree that this is not, and must not be exclusively a debate about saving money. It must be about patient care.

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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