What CER Can and Cannot Tell Us about What We Should Do in Healthcare

6.15.2010  PRESENTER: Norman Daniels, PHD, Mary B. Saltonstall Professor and Professor of Ethics and Population Health, Harvard School of Public Health MODERATOR: James E. Sabin, MD, Director, Ethics Program, Harvard Pilgrim Health Care; Clinical Professor, Departments of Population Medicine and Psychiatry, HMS

Forum Summary

The goal of comparative effectiveness research (CER) is to find a fair way of providing population health services in a setting of limited resources.  For a given condition, CER seeks to address whether one treatment works better than another.  Defining what it means for one treatment to “work better” than another is the main challenge.  The usefulness of CER is constrained by internal and external limitations.

Internal limitations are the result of questions the CER will never be able to answer.  For example, if treatment A is more effective than treatment B but also costs more, should one use treatment A or B?  If A is the only treatment for a disease, should one use it regardless of the cost?  If A and B are comparatively effective for different conditions, which option should be covered if funds are not available to cover both?  Unconstrained CER leads to unsustainably costly interventions, but ethically justifying a cost threshold for interventions is problematic if not impossible.

CER is also externally limited by the political climate of the United States.  A substantial fraction of the population entertains the baffling idea that the government should not do cost effectiveness analysis (CEA) and that such research should be left to insurance companies, which currently consider costs all the time.  Incentives for healthcare providers must also align with evidence-based guidelines if such guidelines are to be adopted.  Healthcare providers currently have financial incentives to provide costly treatments even when these treatments are not necessary.  If the results of CER are to be acted upon, the system of incentives must change.Post a Comment