Commentary on "How CER Could Pay for Itself—Insights from Vertebral Fracture Treatments"
The authors estimate that reducing the utilization of these procedures by 80 percent would save approximately $725 million annually, more than the $500 million projected annual budget of the Patient-Centered Outcomes Research Institute, the entity created by the Affordable Care Act to support comparative clinical-effectiveness research, or CER.
This article is important because it once again highlights the potential waste in our health care system: dollars spent on medical interventions that have questionable value and may, in fact, be harmful. However, most of the output of comparative-effectiveness research will not be clear cut. That is, the relative benefits and potential harms of treatment choices (including no treatment) for a population being studied is complex, and the "right" choice for each patient will depend not only on the medical circumstances for that patient, but also the patient's preferences and values. Like the "Perspective" authors, I suspect that it will be uncommon for a CER study to demonstrate that a new treatment is never appropriate for any patient, and therefore should never be covered under an insurance policy. Coverage decisions are a fairly blunt instrument for disseminating the findings of CER.
So, if CER is not used primarily for coverage decisions, what is its utility? Clearly, CER will be useful for providers as they develop treatment guidelines and make individual recommendations to their patients. Broadly adopted, CER will help our health system move toward more evidence-based practices and reduce unwarranted variation in treatment, utilization, and outcomes. But as important as it is to inform provider practice, another great promise of CER is patients who are truly informed and engaged in their health care. Currently, many patients facing big health care decisions—Surgery versus medical management? Intervene now or wait and see?—receive fairly limited information on the relative benefits and risks of treatment choices.
CER, as defined by the Affordable Care Act, will compare the "health outcomes and the clinical effectiveness, risks, and benefits of 2 or more medical treatments [and] services." Armed with this information, patients, in partnership with their providers, can decide what their own "best" choice is. Interestingly, when fully informed and given the choice between two reasonable treatment options, patients often choose the less-invasive, and less-expensive, procedure.
Returning to Elshaug and Garber's example, even if coverage for vertebroplasty were not withdrawn, how many providers would recommend it if they knew it offered little or no benefit and was potentially harmful? And how many patients would voluntarily choose the procedure?
Yes, CER can help identify potential waste in our health care system, but the greatest value may be that it can support providers in providing the best care, and empower patients to make the best personal choice when reasonable alternatives exist.