Monday, December 12, 2011

Republicans and Ineffective Medicine

Incidental Economist noted an interesting story from a few years ago by Shannon Brownlee in the Washington Monthly, it is well worth reading in its entirety.  The gist of it is that there is very little research on the comparative effectiveness of medical treatments.  So when a doctor recommends treatment x, there is a good chance there is no scientific basis for saying that x is a better choice then treatment y.  The consequences of this can be horrific:
For example, surgeons long assumed that a radical mastectomy for breast cancer, removing not just the breast but the underlying chest muscle and the lymph nodes under the arm, was the only way to get every last cancer cell. Then a massive, multimillion-dollar clinical trial launched by the NIH in the 1990s found that lumpectomy with radiation was just as effective, not to mention less traumatic for many women. Many patients and doctors also fervently believed that high-dose chemotherapy was a woman's best hope when she had advanced breast cancer. The brutal regimen was used for twenty years before clinical trials finally demonstrated that it was no more effective than standard, far less punishing doses of chemo. During those twenty years, an estimated 9,000 women were killed not by their cancer, but by the high-dose treatment.
You'll need to read the story to understand all the reasons why we do so little research in comparative effectiveness, but one cause stands out because of its intentional character.  The first Bush administration created an agency that could deal with this problem, the Agency for Health Care Policy and Research (AHCPR).
Democrats and Republicans alike hoped that the AHCPR's research would help rein in costs by giving doctors better direction, and offering payers—especially Medicare—the ammunition they needed to make evidence-based coverage decisions. More significantly, the agency promised to improve the quality of health care by helping to ensure that doctors would give patients the treatments they really needed—and refrain from giving them care that could harm them.
Unfortunately, the agency did its job and released a study on back pain in 1994 that was unfavorable to back surgeons.  The surgeons got up in arms and found a champion on capitol hill in the new Speaker of the House, Newt Gingrich.  Although he failed in his goal of eliminating the agency, he succeeded in restricting its mission.  "Now, the AHCPR would merely be a 'clearinghouse' for data, which meant it could no longer offer Medicare explicit guidance when it came time to determine which tests, treatments, and procedures to cover." 

Simply put, Newt worked to keep healthcare stupid.  The consequences of that stupidity are obvious:  rampant price inflation, unaffordable premiums and increasing numbers of uninsured, and oh yeah, a bunch of guys who were rendered impotent and/or incontinent for no good reason.

You might think that this would be an issue given Newt's front-runner status for the Republican Presidential nomination, and in a different world it would be.  But in this world making healthcare stupid isn't exceptional for the Republican party, it is the rule.  Just look at the treatment of Don Berwick, Obama's nominee to head the Centers for Medicare and Medicaid Services.  He served a year under recess appointment before being filibustered out of office by Senate Republicans.  His awful crime?  You guessed it, promoting medical effectiveness. I won't even go into IPAB.

All of this leads to a question:  What is it about ineffective medicine that so appeals to Republicans?

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