By Prudence L. Gourguechon on 9/27/2009 10:03 AM
Suddenly I realized I never heard the phrase “evidence based medicine” anymore. I wasn’t hearing about “pay for performance” either. Not to mention “medical necessity”. But now the buzzword “comparative effectiveness” is always in the air, coming up in every discussion of health care reform, and it started to make me very nervous.
I had my arguments against Evidenced Based Medicine lined up (when it was used to plan policy, as opposed to as a legitimate research tool). I had my arguments against Pay for Performance worked out (it seemed to have a taint that went against a couple of thousand of years of medical culture and ethics). But realized I didn’t have the slightest idea what was going on with Comparative Effectiveness, and what its implications were for psychoanalysis. It didn’t sound good though.
Where do these buzzwords come from? Remember “Medical Necessity”? You didn’t learn about it in medical school, you didn’t know what it really meant, but suddenly, a decade or so ago, it was affecting peoples’ lives on a daily basis. At the time, I became obsessed with that phrase too. These phrases, quasi scientific or scientific, often generated in the fields of academia, government or insurance (I guess), are picked up and tossed around and begin to seem like they themselves have scientific validity. When maybe they don’t.
In other words, has policy related to Medical Necessity vs policy related to Evidence Based Medicine vs policy related to Comparative Effectiveness been subjected to, say, randomized placebo controlled experimental study? Has any of their evidence basis been proven? Have comparable effectiveness studies been done comparing them? I doubt it.
The thing about comparative effectiveness that is both appealing and terrifying is that it can be applied using a variety of indicators—health, cost, etc. Just as we were told on the kindergarten playground, words are very powerful.
What worries me most about all these schema is how they handle the necessary uniqueness of every patient's treatment plan. Each of them draws conclusions based on broad population characteristics. And I have no particular reason to doubt the accuracy of the data. But it doesn't reflect the individual variations that we psychoanalysts take into account -- and follow-- in excruciating detail. And so do doctors who manage patients diabetes, high blood pressure, rheumatoid arthritis, autism and so one.
And what about treatments for which a comparative efficacy study is virtually impossible--psychoanalysis for example? So far, wise legislators have placed restrictions on the use to which comparative efficacy data can be put. We need to remain vigilant about tracking these restrictions.
For some background on Comparative Effectiveness, see this paper from the Congressional Budget Office, December 2007
"Research on the Comparative Effectiveness of Medical Treatments"
http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf |