Healthcare Chronicles: Technology Assessment's Triumph?
April 22, 2009
Daniel Callahan
by Daniel Callahan
This report originally appeared in the March 2009 issue of DOTmed Business News.
President Obama's triumph in pushing a massive economic stimulus bill through Congress was matched for many health care reformers by their success in getting $1.1 billion for technology assessment (TA) included in the package. TA has long been a reformer's favorite for an obvious reason: too little is known about the efficacy of medical treatments and of the drugs and medical devices used in those treatments. What works and what doesn't work? If we could get proper answers to that basic question, patients would get better care, physicians would have an empirical basis for their medical judgments and our health care system could save a large amount of money.
Yet, if the validity of TA is little in question, it has had a troubled political history, invoking as much suspicion as admiration over the years. A National Center for Health Care Technology was established by Congress in 1978 and then killed in 1981. Another agency, The Agency for Health Care Policy and Research, was set up in 1985 but was neutered in its effectiveness (and renamed) by Congress in 1994. The complaints of physicians and industry in the first case, and physicians in the second, did them in. Industry was fearful of economic harm from adverse findings and threats to profitable innovation, and physicians saw a potential challenge to their sovereignty in deciding on the best treatment for their patients.
The same forces are at it once again and using the same game book, whose pages must be well-thumbed by now. The Partnership to Improve Patient Care was organized to meet the latest threat from TA. A spokesman for the coalition said the research may be used "in an inappropriate manner that may limit treatment options for patients."
That comment voices the physician worries. The industry suspicions focus on the possibility that the cost of a drug or medical device may be taken into account with TA, the first step down the slippery slope to price controls. An effort to allay both the medical and industry anxieties was expressed in a comment by the House-Senate conferees: "the conferees...do not intend...the funding...to be used to mandate coverage, reimbursement, or other policies for any public or private payer." How binding that statement may be as the research gets underway is unclear.
The worried opponents do not deny the value of TA, at least in some general way. It is the use to which it may be put that is the sticking point. But that leaves them in a vulnerable place. How much latitude should physicians be allowed when determining how to treat patients? Should they be free to ignore solid scientific evidence that counsels against their judgment? Should they be allowed to put their patients at risk if they choose to disagree with research findings? Those would seem the obvious implication of erecting an impenetrable obstacle to protect physician rights. I am not sure many of us would choose to be in the care of such doctors.
As for industry, it has to come to grips in a courageous way with the economic reality of current technological medicine. That medicine is responsible for an estimated 50% of annual cost increases, now in the 7% per annum range, and with a projected doubling of US health care costs from $2.4 to 4.2 trillion in a decade. The fallout is already visible, in declining employer insurance, a rising number of the uninsured, and with considerable economic misery, even for those already insured.
Industry should be willing to take its chances with a tough-minded TA, taking both quality and costs into account. That course might be risky, but not nearly as dangerous as the protectionist opposition to an open border between research evidence and needed economic and clinical regulation. That opposition will harm all of us.
Daniel Callahan, Ph.D. is Research Scholar, President Emeritus, and
Co-Founder of The Hastings Center, an independent, non-partisan, non-profit research institute in Garrison, N.Y. In recent years, Callahan has concentrated his attention on health policy and research policy.
This report originally appeared in the March 2009 issue of DOTmed Business News.
President Obama's triumph in pushing a massive economic stimulus bill through Congress was matched for many health care reformers by their success in getting $1.1 billion for technology assessment (TA) included in the package. TA has long been a reformer's favorite for an obvious reason: too little is known about the efficacy of medical treatments and of the drugs and medical devices used in those treatments. What works and what doesn't work? If we could get proper answers to that basic question, patients would get better care, physicians would have an empirical basis for their medical judgments and our health care system could save a large amount of money.
Yet, if the validity of TA is little in question, it has had a troubled political history, invoking as much suspicion as admiration over the years. A National Center for Health Care Technology was established by Congress in 1978 and then killed in 1981. Another agency, The Agency for Health Care Policy and Research, was set up in 1985 but was neutered in its effectiveness (and renamed) by Congress in 1994. The complaints of physicians and industry in the first case, and physicians in the second, did them in. Industry was fearful of economic harm from adverse findings and threats to profitable innovation, and physicians saw a potential challenge to their sovereignty in deciding on the best treatment for their patients.
The same forces are at it once again and using the same game book, whose pages must be well-thumbed by now. The Partnership to Improve Patient Care was organized to meet the latest threat from TA. A spokesman for the coalition said the research may be used "in an inappropriate manner that may limit treatment options for patients."
That comment voices the physician worries. The industry suspicions focus on the possibility that the cost of a drug or medical device may be taken into account with TA, the first step down the slippery slope to price controls. An effort to allay both the medical and industry anxieties was expressed in a comment by the House-Senate conferees: "the conferees...do not intend...the funding...to be used to mandate coverage, reimbursement, or other policies for any public or private payer." How binding that statement may be as the research gets underway is unclear.
The worried opponents do not deny the value of TA, at least in some general way. It is the use to which it may be put that is the sticking point. But that leaves them in a vulnerable place. How much latitude should physicians be allowed when determining how to treat patients? Should they be free to ignore solid scientific evidence that counsels against their judgment? Should they be allowed to put their patients at risk if they choose to disagree with research findings? Those would seem the obvious implication of erecting an impenetrable obstacle to protect physician rights. I am not sure many of us would choose to be in the care of such doctors.
As for industry, it has to come to grips in a courageous way with the economic reality of current technological medicine. That medicine is responsible for an estimated 50% of annual cost increases, now in the 7% per annum range, and with a projected doubling of US health care costs from $2.4 to 4.2 trillion in a decade. The fallout is already visible, in declining employer insurance, a rising number of the uninsured, and with considerable economic misery, even for those already insured.
Industry should be willing to take its chances with a tough-minded TA, taking both quality and costs into account. That course might be risky, but not nearly as dangerous as the protectionist opposition to an open border between research evidence and needed economic and clinical regulation. That opposition will harm all of us.
Daniel Callahan, Ph.D. is Research Scholar, President Emeritus, and
Co-Founder of The Hastings Center, an independent, non-partisan, non-profit research institute in Garrison, N.Y. In recent years, Callahan has concentrated his attention on health policy and research policy.
