Evidence-Based Medicine, Cost-Effectiveness
and Medicaid Reform: Concerns Submitted by Laura Remson Mitchell on behalf of the California Disability Alliance and the California Work Group on Work Incentives and Health Care Two concepts that have gained increasing popularity in health policy discussions of late are “evidence-based medicine” and “cost-effectiveness.” Both have been mentioned with regard to Medicaid reform. For this reason, we feel we must comment. If properly applied, both evidence-based medicine and cost-effectiveness have the potential to improve the quality of health care provided to Medicaid beneficiaries and, over time, to reduce costs, thereby allowing more people to be served. Unfortunately, however, these terms are most frequently mentioned in connection with reforms that are intended first and foremost to reduce health costs, not to improve care. Though it may not be stated specifically, it seems clear from the timing of Medicaid reform during a serious budget crisis—and from the Governor’s stated objectives—that the driving force behind reform is fiscal. I’ll address these two concepts one at a time. Evidence-Based Medicine While it’s certainly desirable for health-care programs, including Medicaid, to follow treatment guidelines that are based on the latest research and best clinical practices, the evidence considered in “evidence-based medicine” can comprise a number of very different things. Each of those possibilities can result in a different set of guidelines.
1. Available clinical studies may have been done on patient populations with different demographics and different co-morbidities than the particular patient being seen by the Medicaid provider. How would such studies be applied in a clinical setting? Would the results of a study on young, healthy, white males be applied to treatment of a 65-year-old Latina woman with post-polio syndrome and heart problems? Would the absence of an approved study specifically on people who share the patient’s demographic and medical profile mean that only the standard (or least-expensive) treatment would be covered—even if that treatment might be ineffective or harmful for the patient? 2. For many conditions, there are no clinical studies at all. That’s especially true for relatively rare or newly identified conditions and for those affecting relatively small populations, particularly those without much political or economic power. Will the absence of studies translate into the absence of appropriate treatment for these conditions and populations—even when there is a treatment that has a record of success based on the clinical experience of the physician and/or as reported in medical literature? If so, the system will be discriminating against many of the very people Medicaid is intended to serve—including people with disabilities. 3. Results of various studies can and often do conflict. If “scientific evidence” is used as a basis for covering or not covering various treatments, the people who select the studies to review for that “evidence” will have tremendous power over the health-care options of Medicaid beneficiaries. How will they be selected? What kind of oversight will there be to assure that there is no bias (intentional or unintentional) in the selection of the studies used for developing “evidence-based” guidelines? How often will the “evidence” be updated or re-evaluated? Long time lags could deprive Medicaid beneficiaries of the most effective treatments for their health needs not because the evidence doesn’t exist but rather because the state hasn’t been keeping up. As long as the research is for the purpose of informing physicians—not for directing or restricting their treatment options—the system can be self-correcting and can lead to better health care. But if “evidence-based medicine” means using these guidelines as a kind of one-size-fits-all treatment grid, it will lead to poor health outcomes and potentially greater costs. 5. We recognize that scientific evidence can be valuable in developing treatment guidelines. However, those guidelines must be voluntary, allowing physicians and other health-care providers to work in partnership with their patient to find the most appropriate treatment. Mandatory “guidelines” would be extremely dangerous for people with disabilities, serious chronic health problems, and rare diseases, as well as for members of many racial and ethnic minority groups.
1. The Oregon approach to Medicaid cost-containment has been positively cited several times in regard to Medicaid reform. And, in fact, there is much to learn from the experience of Oregon—and from the experience of other states as well. However, we see some significant problems. For example:
Cost-Effectiveness. Like “evidence-based medicine,” the concept of “cost-effectiveness” can have either positive or negative impact on health care for Medicaid beneficiaries. The key issue here is how “cost-effectiveness” is viewed. The cost-effectiveness of a treatment can be evaluated:
To the extent that such inappropriate or harmful treatments result in secondary or tertiary health problems or disabilities, the assumed cost-effectiveness for the total population may turn out to be illusory. In effect, the failure to look at cost-effectiveness in terms of what is cost-effective in the individual patient’s case, not just what appears to be cost-effective for the group overall, may well wind up costing the Medicaid program—and the state—more, not less, in the long run. As with evidence-based medicine, the danger here is that instead of being used as a guideline—a way to keep costs down when it doesn’t harm patient care—the concept will be applied indiscriminately, with no regard to individual patient differences. Good medical practice and good health outcomes depend not only on the use of reliable evidence-based guidelines but also on a team approach to care in which physician and patient work together as partners to determine the best treatment choice. While it is reasonable for the system to promote the use of the least-expensive treatment that will provide the desired health-outcome with the least harmful side effects, it is not acceptable for cost to be the driving factor in treatment decisions nor for cost considerations alone to exclude a legitimate treatment option that the doctor believes is medically necessary and more appropriate for a particular patient than treatments on some formulary (whether for drugs or for other treatments). Conclusion: Efficient use of health-care resources cannot be achieved by looking only at what appears to be cost-effective for the total Medicaid population or for the average patient or even for the average patient with a particular health condition. It requires the flexibility to provide timely treatment that is cost-effective for the individual patient. (Copyright 2004 by Laura Remson Mitchell) Return to LRM's Home Page. |