Trying to demystify comparative effectiveness

May 21, 2009 – 11:03 am by Chris

While at BIO 2009, I had the opportunity to speak with Paul H. Keckley, Ph.D., executive director, Deloitte Center for Health Solutions, and Terry Hisey, vice chairman and U.S. Life Sciences leader for Deloitte LLP. Just this Tuesday, Deloitte issued Dr. Keckley’s newest paper, which takes a look at comparative effectiveness as it is used in the healthcare programs of four countries – Australia, Canada, Germany, and the United Kindom.

As the United States begins to debate what shape healthcare reform should take (and no one at this moment is certain of what that will be), Dr. Keckley thought it would be a good idea to compare and contrast how comparative effectiveness is used elsewhere. Some like to use comparative effectiveness as a bogeyman in the healthcare debate. For example, Dr. Robert Goldberg, writing at the blog DrugWonks, says comparative effectiveness is already being used to ration healthcare in the United States, based on the decision that the Centers for Medicare and Medicaid Services refuses to cover CT colonography as a screening tool for asymptomatic, average-risk Medicare patients. CMS’ decision was based on a large-scale clinical trial, which Dr. Goldberg seems to take exception to. “Why not try getting evidence of cold fusion?” he asks.

Dr. Keckley says his paper is not intended to espouse a particular position on comparative effectiveness. “It’s to show what it is and what it isn’t,” he says. “In some systems, it’s used as a big stick. In others, it’s used in an advisory capacity.”

According to Dr. Keckley, at its best, comparative effectiveness can cut out a lot of the waste and inefficiencies that plague the U.S. healthcare system, which is currently costing $2 trillion and is rising in costs at two-and-a-half times the rate of the national economy. I quote from the paper:

“Simply stated, clinical decisions about health care interventions, for individuals or populations, are not always informed by adequate evidence of the clinical effectiveness of those interventions. Similarly, massive investments in health care interventions are not necessarily driven by solid evidence of effectiveness. When treatment alternatives exist, there may not be evidence of how those alternatives compare in regard to their effectiveness. Building capacity to expand the study, monitoring and clinical application of the relative effectiveness of healthcare interventions is a major challenge in reforming the U.S. healthcare system.”

What shape could a comparative effectiveness system actually take in the United States? Dr. Keckley says that is still up in the air.

“It could be an advisory body that would just inform Joe Plumber on the efficiency and effectiveness of drugs, or it may end up the strength of the Federal Reserve,” he says. “I don’t think anyone has written a book on this thing yet.”

One thing needs to made clear when talking about how comparative effectiveness might be officially deployed in the United States and looking at what has been done in other countries, Dr. Keckley says. “Most of these countries had spent at least 10 years building their comparative effectiveness platforms and has them going for another 15 years,” he says. “In the U.S., it’s not going to be done in an election cycle.”

Additionally, what other countries are doing with comparative effectiveness was created to work with their healthcare systems, and simply cannot be bolted on to what the United States has done or what will do, Dr. Keckley says.

Mr. Hisey points out that for the pharmaceutical industry, comparative effectiveness may be a blessing in disguise. “The industry will have to get a little more efficient about drug development, and there will be less chasing after ‘me-too’ drugs,” he says.

I leave you with Dr. Keckley’s final thoughts from his paper:

“Comparative effectiveness need not be a reversal of the strengths and enormous success of the U.S. healthcare industry. Rather, it can be an engine for renewed innovation in the design and delivery of evidence-based care. The lessons from other countries’ approaches to comparative effectiveness are instructive but a cut-and-paste approach will not work in the U.S. A ‘tools, not rules’ approach, with industry and policy makers working side by side, will result in a comparative effectiveness model that delivers better value and lower costs.”