nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, June 5, 2010

Will Comparative Effectiveness Be Acceptable To Patients...Not Likely, Study Says

Waste and duplication in medicine is best managed by the "owners" of the bodies and minds that require health care:  the patients.

A study published June 3 in the journal Health Affairs shows that patients are going to have a tough time buying in to comparative effectiveness as a decision-making tool.

This is an important finding, and ominous for those who anticipate success from the major overhaul of the US health care system.  All the brouhaha about cost is over now:  it's clear even to those who claimed that efficiencies in the law would help control health costs that this isn't true (now that the law is passed, they conveniently admit that "initial estimates" were wrong).  In fact, it's going to cost a lot, and some analysts say that it will cost as much or more than if we had done nothing.

So, to prevent the whole process from foundering on runaway costs, Congress and the Administration have set in place a mechanism to pursue "the generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat and monitor a clinical condition, or to improve the delivery of care" (comparative effectiveness)

Sounds great.  To put this in perspective, comparative effectiveness is part of what's been pushed as "evidence-based medicine," an effort to fit patients' health care needs into a formula for treatment:  the best way to treat disease A is treatment B.  Evidence-based decision-making has been taught in medical schools for a generation.  To be fair, proponents of evidence-based medicine realize that a "one-size fits all" approach doesn't always meet individuals' needs.  But the starting point is that everybody is the same, adhered to unless otherwise justified.

To analyze beliefs patients have about information of this kind, the authors surveyed a group of employed and insured adults.  They found that there is "there is a fundamental disconnect between the central tenets of evidence-based health care and the knowledge, values, and beliefs held by many consumers."

[First of all, distrust anyone who thinks patients are "consumers."  Health care is not grocery shopping.]

[And they are not "clients,' either.]
The 'pervasive themes' from respondents, according to the authors, were 'more is better, newer is better, you get what you pay for, (and) guidelines limit my doctor's ability to provide me with the care I need and deserve.' (WSJ Health Blog, June 3)
The individuals surveyed thought that medical guidelines "represent an inflexible, bargain-basement approach to treating unique individuals."  The authors think the respondents are misguided, but the study participants are right to be suspicious.  In other countries, governments have used guidelines to set dollar limits on what care will be authorized (such as the financial formula in Great Britain that authorizes treatment only if extends life a year and costs less than a pre-determined amount). 

Sometimes perceptions ARE reality, and it's ironic that our belief in constant progress has been so ingrained that when the purveyors of change and reform, who are responsible for that attitude, say, "Wait.  Newer is not always better," they're shocked, shocked, that people don't believe them.

And it's disgraceful that having sold the message of reform and progressive improvement in the human condition, they want to say, "Actually we want you to subscribe to only that improvement we think you ought to want."  (I'll save for another day my belief that this is the fundamental flaw with the progressive movement:  the "soft tyranny" where government promises to provide happiness if only you don't question the happiness offered, and give up your freedom to choose.)

What I find most telling about this study is the authors' assumption that the way ahead is not to question comparative effectiveness as a tool for government.  Instead policy makers will "need to translate evidence-based health care into accessible concepts and concrete activities that support and motivate consumers."  That is, they need to use the right words to get people to buy into the program.  Patients aren't smart enough to figure it out on their own.

Progressives and reformers want to "show" people (using those "clear" words) what they should want for their medical care.  And if just educating people to seek what they should want doesn't work, then people need to be compelled--through dietary laws (bans on fast food restaurants), sin taxes (sugar beverages, salt fines, etc), and other regulations that restrict people's choices to the "approved" one.

My personal belief is that medical treatment doesn't have to be a mystery for patients.  But it does require them to take charge of their care.  Comparative effectiveness has its place, but it's what doctors should study and bring to the examining room; after all, that's what medical education is about, bringing knowledge to the patient, balancing the knowledge of what works against the patient's needs and desires, forming a contract that develops trust, and succeeding in a healing partnership.

I don't see any role for the government in this.

I've written before how patients can become equal partners in seeking medical care.  The complaint that patients are at a disadvantage as "consumers" is true, but only because they haven't been given the right and responsibility to learn to make choices.  They're at a disadvantage because there's no incentive for them to engage in their health care choices.  See my article on the Whole Foods alternative.

One word of caution.  For the 2-1 majority of Americans who want to repeal the health care reform law, be careful what you ask for.  Freedom to choose means taking responsbility for the choice.

But what more intimate responsibility is there?  We're not talking about some public service like the Fire Department.  This is your body, your self.

Doc D

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