Congress appropriated $1.1 billion—the total worth of 1,100 millionaires—to “comparative effectiveness research” (CER). It promised that CER would not turn out to be “cost-effectiveness research”—and the rationale for treatment rationing and denial—although it defeated a proposed amendment that would have codified that promise into law.

In his talk to the AMA, Obama said, “[We]...need to do...figure out what works, and encourage rapid implementation of what works into your practices. That’s why we are making a major investment in research to identify the best treatments for a variety of ailments and conditions.” He wants a system “where...doctors can pull up on a computer all the medical information and latest research they’d ever want to meet that patient’s needs.”

Unlike other research funded by the $30 billion spent annually by the National Institutes of Health (NIH), or by pharmaceutical companies, universities, and others, CER has nothing to do with discovering better treatments or achieving a better understanding of disease. CER is simply supposed to rank existing treatment methods.

The Institute of Medicine (IOM) has winnowed down some 1,300 topics suggested by “stakeholders.” Of the IOM’s 293 recommended primary and secondary research priorities, 50 (by far the largest number) pertain to “health care delivery systems”; 29, to racial and ethnic disparities; and 22, to functional limitations and disabilities (John K. Iglehart, N Engl J Med, posted 6/30/09).

Half the recommended primary research priorities for delivery systems concern how or where services are provided, rather than which services are provided.

An IOM committee also recommends “determining the most effective dissemination methods to ensure translation of CER results into best practices”—i.e. enforcement.

The goal of CER is indistinguishable from that of managed care: “delivering the right care to the right patient in the right place at the right time.”

Cancer is the focus of only six primary CER topics, of which one is related to congressional concern about increased use of advanced imaging.

The $1.1 billion is only a down payment. A new nonprofit corporation is expected to carry on, financed by a $1 annual “contribution” from each Medicare beneficiary and each privately covered life (ibid.).

CER, by proponents’ own admission, achieves nothing in itself. It merely “represents a significant investment in one of the translational steps toward improving the quality of health care for all” (Patrick H. Conway and Carolyn Clancy, N Engl J Med 2009; posted 6/30/09).

Operationally, CER means setting up a bureaucracy and dividing the funding among stakeholders. The content for the materials and methods section of a standard research report—consent, an institutional review board, control groups, validated data collection tools, defined endpoints, statistical procedures—appears to be absent.

There is no evidence that CER will decrease costs, improve quality—or produce any scientifically meaningful data. But for its proponents, there is no danger that the reformed system will be proved inferior, as there is no “usual care” arm to the protocol.

For example: determining patients’ needs—by talking to patients. Determining the comparative effectiveness of various treatments in individuals—by interviewing and examining patients. Determining the cost and value of differing options—by permitting prices to equilibrate in a direct-payment model.

Additional information:

• “Organization on High: Expanding Use of Physician Examination Scores,” by Hilton P. Terrell, M.D., Ph.D., J Am Phys Surg, Spring 2009.
• “What Does the Stimulus Bill Mean for Medicine?” AAPS News of the Day 2/24/09.
• “Medical Information and Bureaucracy: F.A. Hayek and the Use of Medical Knowledge,” by Hilton P. Terrell, M.D., Ph.D., and Timothy D. Terrell, Ph.D., J Am Phys Surg, Fall 2005.