The Holy Grail of Evidence-Based Medicine
I am probably more optimistic than most healthcare professionals about the value of evidence-based medicine. To me, it is a tool that can be used or misused to achieve certain goals. Misuse doesn't mean the tool should be tossed out—it just needs to be policed.
As the former medical director for several health plans and for a large hospital, I used EBM to develop medical policies and make decisions about benefit coverage. Program participants felt that EBM made the decision-making process rational, objective, and based on facts, rather than on personal anecdotes, expert opinion or “that's the way we've always done it” methodology. Misuse generally occurs when there is profit or prestige involved. If the evaluation and funding for medical research (the basis for EBM) were moved to a more regulated environment, I believe the instances of misuse would decrease and be easier to spot.
The new administration has made healthcare a major focus and supports the idea of evidence-based medicine. Congress has approved President Obama's proposal to spend $1 billion to support comparative effectiveness research. The goal is to identify which medical products and procedures are most effective—and ultimately improve healthcare and decrease unnecessary spending.
The use of comparative effectiveness research risks cost-based restrictions. However, we may be headed for that now, but without clinical and value outcomes added to the mix. It's disturbing to watch when peer-reviewed research is sullied by undisclosed financial ties, whether they influenced the research or not. This appears to create a fraudulent base for clinical decision making.
Another danger for evidence-based medicine is the “R” word: Rationing. This issue is always raised as a red flag when EBM or comparative effectiveness is discussed, but the argument is a red herring. Rationing happens around the world because every country, except the United States, has confronted the reality that unlimited demand cannot be balanced with limited resources. Those countries have decided how to allocate their limited resources to best serve their citizens and the result is the “queue system,” or the wait for a limited resource.
Congress has also taken steps to help ensure that care cannot be rationed. In fact, the American Recovery and Reinvestment Act of 2009 stipulates that comparative effectiveness research cannot be used to “mandate coverage, reimbursement or other policies for any public or private payer.”
Evidence-based medicine doesn't cause rationing—rationing is the result of government policy decisions. Instead, EBM is a tool used to decide how much of a resource is needed and how patients are going to access it, based on medical need and value received. Linking rationing with EBM is a political trick used by those who don't want to be held accountable for the reality of limited resources and the necessity of telling someone no.
In this country, we routinely tolerate de facto rationing every day by limiting access to medical services based on ability to pay—a form of social justice that most other countries find incomprehensible. Just try getting access to a liver transplant is this country if you are self-employed, can't get health insurance, but make too much money to get on Medicaid. It can't be done.
The one danger of using EBM is the failure to realize that most of the things we do in medicine are not supported by good, solid medical evidence. The key policy behind EBM is a commitment to allowing practitioners to continue their current practices until EBM supports a change. We can't simply declare that we're going to stop doing things because they don't have an EBM basis because that would wipe out most of what we do. I think that key declaration of principle would take away most of the anxiety for most practitioners, but mostly on a generational basis. You can't do much about folks who are:
- Simply opposed to change
- Too far into their careers to deal with change
- Have a financial stake in resisting/opposing change
My experience with setting and administering medical policy for several million enrollee-years tells me that approximately 20% to 25% of the annual healthcare dollar is wasted on redundant, low-value, useless or even harmful healthcare services. A well-organized, refereed approach to EBM would help with this problem, but it would be a long-term effort. The current administration is correct in stating that we can probably cover all of the 47 million uninsured Americans with the savings achieved by EBM, but they are far too optimistic about how long it will take to achieve that goal.
Applying evidence-based medicine or comparative effectiveness to medical policy need not be a foreign concept. My current employer helps hospitals improve their financial and clinical performance and does that quite well. That doesn't mean we contract for the cheapest items, but instead we choose items that provides the greatest value at the lowest cost. We also look at appropriate utilization and whether there are opportunities for clinical improvement. That is what EBM is all about.
That logic can prevail if applied more broadly. I'm only one physician, and many of my colleagues share my viewpoint. Nevertheless, healthcare won't get better unless doctors engage in serious discussions about how to change it.
Mark Hochstetler is vice president of clinical affairs at VHA Inc. He can be reached at firstname.lastname@example.org.
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