Managed Healthcare Executive - April 2009 - (Page 17) {EXECU TIV E PROF ILE} Support and opposition to CER policy America’s Health Insurance Plans, Consumers Union and others applaud the CER policy enacted in the stimulus bill. Helen Darling, president of the National Business Group on Health, calls it “a modest investment that could pay substantial dividends over the long term.” The Academy of Managed Care Pharmacy has been an advocate for many years and was part of the coalition that helped establish a CER program at AHRQ. Executive Director Judith Cahill said in a statement, “The funding levels in the bill for comparative-effectiveness research on new and existing medical therapies will ensure the development of data that is free from political pressures.” Director of the Of ce of Management and Budget Peter R. Orszag, who was instrumental in the policy design, has long called CER a cost-saver. The Pharmaceutical Research and Manufacturers of America president and CEO, Billy Tauzin, issued a statement of quali ed support for the policy noting that “the important work of legislating a long-term policy framework for comparative effectiveness remains to be done.” Conservative groups, however, believe the provisions will be used as a stepping stone to government control of healthcare or clinical-practice mandates. Conservatives also predict that the clinical CER will be, in reality, fuel for coverage denials, even though a Congressional report accompanying the nal bill noted research was not intended to be used to “mandate coverage, reimbursement or other policies for any public or private payer.” Some warn that the research will produce nothing more than broad conclusions, reducing access to treatments that would be appropriate for certain subpopulations. The nal bill addresses concerns, saying research must include women and minority groups. Some drug and device makers are concerned that CER will delineate winners and losers, putting their sales in jeopardy. Opponents contend that synthesis of the research should be left to the private market. Although nothing prohibits private plans from using the data for coverage decisions, it is unclear how public plans will use the information. Additionally, experts are somewhat concerned that political pressure from various groups in response to research ndings (i.e. ndings that cast their clients in bad light) could render the program useless. —Julie Miller Comparative Effectiveness Funding The American Recovery and Reinvestment Act provides $1.1 billion: NIH: $400 million HHS: $400 million AHRQ: $300 million technologies, drugs, devices and treat- procedures will be especially critical in ments,” Holly Potter, vice president of CER studies. public relations for Kaiser Permanente, The largest proportion of healthcare tells MHE. costs come from medical procedures delivered by physicians and hospitals. More than Drugs Hospital charges account for 31 to 33 In clinical study, there is a market ten- cents of every healthcare dollar, and dency to focus on the e ectiveness of physician charges account for about 19 drugs and devices, but that approach cents. Drug expenditures only account misses the point. Most of today’s “ex- for about 10 cents, and devices account plosive new innovation” a ects medical for even less than that, she says. procedures, Wilensky says. She believes “If we are actually going to slow comparing outcomes associated with down spending in healthcare, that means hospitals, physicians, industry, drug and device people and equipment manufacturers are not going to see the kinds of increases in income that they’re used to seeing, and they’re not going to take kindly to that,” she says. “You can count on the fact that if there is any downward pressure in the very high-spend areas to do less-aggressive interventions, physicians will claim that government, private insurers, whomever the ‘they’ are, are trying to keep them from providing the best healthcare they can for their patients.” Wilensky says the only e ective counter will be good evidence to show that less or less-complex care can be better care. She cautions the industry that even though clinicians are only delivering recommended care about half the time, according to a groundbreaking 2003 RAND Health report, any initiatives that appear to meddle in the doctor-patient relationship will likely be spurned by some in the provider community. The key to moving the healthcare industry to a better position is making CER information available, complemented by a reimbursement system that rewards the clinicians and institutions that practice appropriately and e ciently according to the evidence, while also penalizing those who don’t, she says. “If we don’t change the incentives, and we don’t have a good information base behind it, we have no hope,” Wilensky says. MHE APRIL 2009 17
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