Medicolegal Issues

Dare to Compare


A new concept on Capitol Hill could reshape physicians’ treatment choices: comparative effectiveness research, or CER.

CER is a set of standards for examining the effectiveness of different therapies for a specific medical condition or set of patients to determine the best option. It may involve comparing competing medications or analyzing treatment approaches, such as surgery, devices, and drug therapies.

The healthcare community—and Capitol Hill—should keep an eye on CER.

“We need to look at evidence-based medicine and see what is the most effective treatment,” says Andrew Fishmann, MD, FCCP, FACP, co-founder of Cogent Healthcare and director of intensive care at Good Samaritan Hospital in Los Angeles. “The answer may also be the most expensive, but other factors such as decreased length of stay and fewer complications can help bring that cost down.”

One example that CER might address is back surgery—an issue many physicians cannot agree on. “There are billions of dollars spent on back surgery that may not be necessary,” Dr. Fishmann points out.

CER could ultimately provide guidelines that would standardize treatments for all types of conditions: “A big organization like Cogent would like to think that a patient with pneumonia receives the same treatment whether he’s in California or in Mississippi—but there are many reasons this is probably not true,” says Dr. Fishmann.


Heart Data Online

You can now review data on mortality rates for heart attack and heart failure in hospitalized Medicare patients on the government’s Hospital Compare Web site at Available data include 30-day risk-standardized mortality measures for patients with hospital discharge diagnoses of acute myocardial infarction or heart failure for all acute care hospitals in the U.S. from July 2005 to June 2006.

Measure Your State

Fifty-one new data snapshots—for every state plus Washington, D.C.—are available from the Agency for Healthcare Research and Quality (AHRQ). The snapshots measure healthcare quality in three contexts: by types of care (such as preventive, acute, or chronic), by settings of care (such as nursing homes or hospitals), and care by clinical area (such as care for patients with cancer or respiratory diseases). The data were collected through 129 quality measures, each of which evaluates a different segment of healthcare performance.


More Money for AHRQ

In June, the Senate Appropriations Committee approved an increase of $10 million for FY 2008 funding for the AHRQ, bringing total funding to $329 million. Additional legislation in the House would add $10 million to that.

MedPAC Favors MS-DRGs

The Medicare Payment Advisory Commission (MedPAC) has urged the Centers for Medicare and Medicaid (CMS) to adopt the Medicare Severity Diagnosis-Related Groups payment system, or MS-DRG, proposed for FY 2008, but recommended some changes. These include refinements to proposed methods for estimating cost-based weights. Online at _rule_comment.pdf. —JJ

CER So Far

The Medicare Modernization Act of 2003 gave CER a jumpstart with $65 million in appropriations and authorized the Agency for Healthcare Research and Quality (AHRQ) to conduct research.

“Since 2004, [the AHRQ has] received $15 million a year for CER,” says Emily Rowe, director of government relations for the Coalition for Health Services Research in Washington, D.C., and a member of the Friends of AHRQ coalition. “They’re pretty limited in what they can produce on that budget, but to date they’ve done some interesting work.”

That work includes eight published reports on treatment options for breast cancer, gastroesophageal reflux disease (GERD), cancer-related anemia, low-bone density, depression, and more, with 20 additional reports “in the pipeline,” says Rowe.

All available reports can be downloaded from http://effectivehealthcare., where results have been published in separate versions for physicians and consumers.

“The most interesting example of [CER from AHRQ] is synthesized research that shows that drugs can be as effective as surgery for severe heart burn,” or GERD, says Rowe. “This shows the promise of CER.”

So AHRQ is at work on CER projects but, says Rowe, “It needs a more serious investment.” Some in Congress agree.

New Laws, More Money

The Enhanced Health Care Value for All Act of 2007 (HR 2184) was introduced by Reps. Tom Allen, D-Maine, and Jo Ann Emerson, R-Mo, in May. This bill would provide $3 billion over five years to fund CER.

Under the legislation, the AHRQ would remain the federal agency charged with supporting CER, but a new comparative effectiveness advisory board would be established, comprising employers, consumers, healthcare providers, researchers, and others. The board would offer advice on research priorities and methodologies.

Some, including the Blue Cross Blue Shield Association (BCBSA), have called for a new executive-branch agency or a new coalition to oversee CER. Dr. Fishmann, who is serving a second term on the National Advisory Council for AHRQ, strongly disagrees. “This is evidence-based medicine,” he stresses. “AHRQ is the perfect entity for this. What an organization like AHRQ will do is look at everything and address the issue impartially.”

Quality, Costs, Results

Congress views CER as a means of saving costs in healthcare, but CER would not provide immediate savings; rather, it’s a first step toward lowering healthcare costs. In fact, House Ways and Means Subcommittee Chairman Pete Stark, R-Calif., expressed concern about “moving” CER legislation this year, because it would require immediate investment without immediate savings.

“I don’t know where you come up with that money when everyone else in healthcare is fighting for more funds,” Dr. Fishmann says of the current legislation. “But Congress can come up with the funds if they want to.”

Rowe won’t speculate on whether the House bill will pass but does say: “The appropriators and budgeters are getting ready to fund this, so that if the legislation passes the money will be there. And interest in CER is gaining in both parties of Congress.”

While legislators focus on costs and savings, healthcare professionals are interested in improving quality.

“It is a quality issue, but a better term is value,” says Rowe. “The idea is, ‘Let’s get what we pay for.’ The U.S. needs better medical outcomes, and the idea of CER is not what treatments costs less but that it’s worth it if you have to spend more if the outcomes are improved.”

And Dr. Fishmann thinks CER will change how we provide care. “It’s going to standardize the delivery of healthcare,” he predicts. “If you don’t follow these standards, someone is going to ask why not—it might be the payer, your colleagues, your hospital.” Once CER reports are available and shared with the public, he points out, “as patients get educated, and payers too, they’ll stop paying for treatments that go against the standard.”

… The idea of CER is not what treatments cost less, but that it’s worth it if you have to spend more, if the outcomes are improved.

—Emily Rowe, director of government relations for the Coalition for Health Services Research, Washington, D.C.

Hospitalists and CER

How will comparative effectiveness affect hospital medicine?

“They’re looking at ischemic heart disease, pneumonia, diabetes, stroke—all hospitalized diseases,” says Dr. Fishmann of current CER projects. “Right now, everyone is practicing their trade, and everyone is doing things differently. I think in terms of hospitalists, it clearly will affect how you treat patients, and for how long.”

Regardless of the current House bill, it seems CER is on the horizon, for hospitalists and for all of healthcare.

“The good news is, I don’t think this is going away any time soon,” says Rowe of CER. “The train has left the station and it’s steaming away.” TH

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