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Truly Reducing Health Care Spending

The April 13 issue of the New England Journal of Medicine includes an important article on how comparative effectiveness research can pay for itself.  In it, the authors describe two procedures to treat osteoporotic vertebral fractures (compression fractures caused by osteoporosis): one in which cement is injected into the vertebral body to support the fractured bone; and one in which a balloon is inserted and inflated in a collapsed vertebral body, restoring the bone’s height before the cement injection.

There were some early studies of these procedures to determine their effectiveness but the studies were flawed in some significant ways. Nevertheless, these procedures were widely adopted because the pain of these fractures is significant and people are desperate for help and help quickly (most of the symptoms of compression fractures abate over time but the waiting can be difficult for many patients).

Recently, these procedures have been studied in a more rigorous way. The more recent evidence about these procedures shows that they are either not effective, or only marginally effective, at treating osteoporotic vertebral fractures. And, even more significant: there are serious risks associated with the procedures – risks such as leakage of the cement, pulmonary problems and even death. The new studies caused the Blue Cross and Blue Shield Association to recommend against coverage of these procedures and the Medical Society in Ontario to determine that these should not be the standard treatment for these fractures.

Comparative effectiveness research has been maligned by some as a form of rationing of health care. Opponents have raised the specter of death panels when describing this process. And, historically, when payers have determined not to cover certain procedures, they have been pressured by some practitioners who perform those procedures and by patients who see it as a greedy insurance company trying to limit benefits for patients.

But, the reality is quite different, as in this example of osteoporotic fractures.

Comparative effectiveness research, done right, can not only reduce health care costs but also unnecessary deaths and disability. Comparative effectiveness research starts with a focus on quality and safety of care and what works clinically. It should be the foundation for evidence based medicine, helping to understand the best ways to treat patients with various conditions.

Anyone who has worked in the field trying to reduce even the rate of increase of health care spending knows that the easiest approaches – squeezing prices paid to providers, introducing wellness programs, providing care management strategies for patients – are all either limited in their effectiveness or marginal in their impact on health care spending. Some may be very good things to do (such as wellness programs and care management) and highly cost effective; but not necessarily cost saving.

True savings in health care come about from more fundamental changes: restructuring how health care is delivered to better coordinate and integrate care (which also involves changing the structure of provider payment incentives in the system), reducing practice pattern variation, and delivering more care based on the evidence of what works, including decisions about what services to cover – and what not to cover.

So what are we talking about in terms of health care trends? Well, for just the two procedures dealing with these particular compression fractures, the all payer national spending in 2008 was $1 billion. That is $1 billion in spending for two procedures that may have done more harm than good. Reducing that spending by even half would make a significant contribution to reducing health care cost trends.

All payers make coverage decisions. Some things are included in the scope of coverage and some are not. Wouldn’t it be better for everyone if those decisions were informed by high quality, nationally funded, and nationally disseminated research? Well, that is the promise of comparative effectiveness research.

Whatever else happens with the Affordable Care Act, for all of our sakes, let’s hope that comparative effectiveness research is here to stay.

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