Medical Treatments: Issues and Options for an

¶ … Medical Treatments: Issues and Options for an Expanded Federal Role" Using Bardach's Eightfold Path" The objective of this work in writing is to assess the work entitled "Research on the Comparative Effectiveness of Medical Treatments: Issues and Opinions for an Expanded Federal Role" using Bardach's Eightfold Path. Bardach's eightfold path includes specific steps for assessment including: (1) Defining the problem; (2) assembling some evidence; (3) Construction of alternatives; (4) selection of criteria; (5) projection of the outcomes; (6) confrontation of the trade-offs; (7) decisions; and (8) telling the story.

Defining the Problem The work entitled "Research on the Comparative Effectiveness of Medical Treatments: Issues and Opinions for an Expanded Federal Role" was published by the Congressional Budget Office in November 2007 and is focused on the rising health care costs and the challenge that these represent for the federal government and private payers alike.

It is noted in this work that there is a "variety of evidence" suggesting that there are existing opportunities to "constrain health care costs both in the public programs and in the rest of the health system without adverse health consequences." (GAO, 2007) II.

Assembling Some Evidence Federal spending on Medicare and Medicaid is noted to have increased and in fact tripling "over the past 30 years…as a share of gross domestic product (GDP), rising from about 1.3% in 1975 to about 4% in 2007." (GAO, 2007) If the costs per enrollee stay on the path of growth over the next four years as they have in the previous four "then federal spending on those programs would reach about 17% of the economy." (GAO, 2007) It is reported that evidence concerning which treatments are most effective for which patients is many times not available.

III. Construction of Alternatives Alternatives stated to be available by the Congressional Budget Office includes the following: (1) Because any private sector entity, such as a health plan has only a limited incentive to produce or pay for information that could benefit many entities an argument can be made for a larger federal role in coordinating and funding research on comparative effectiveness.

(2) In addition, because federal health insurance programs play such a large role in financing medical care and account for such a large share of the budget, the federal government itself has an interest in generating evaluations of the effectiveness of different approaches to health care. (3) If policymakers wanted to expand federal efforts to study comparative effectiveness, the endeavor could be organized in different ways -- for instance, by augmenting an existing agency, by establishing a new agency, by supporting an existing quasi-governmental organization, or by creating a new public-private partnership.

In choosing an organizational arrangement and a mechanism to provide federal funds to it, tradeoffs could arise between the entity's independence from political pressure and its accountability to policymakers and other interested parties. Efforts to bolster comparative effectiveness research would be more likely to change medical practice if the organization coordinating the research was respected and trusted by doctors and other professionals in the health sector. The level of funding required for a new or augmented entity would depend largely on what its additional activities involved.

Synthesizing existing studies or analyzing available data on medical claims would be less expensive than conducting new head-to-head clinical trials to compare treatments but could also yield less definitive results -- and therefore might have a smaller impact on medical practice. (4) Clinical trials could be more persuasive but also more time-consuming, and there is probably a limit to how many comparative trials could be undertaken effectively at any given time.

If privacy concerns could be addressed, having more health records available in electronic form would facilitate the use of such data for research. Studies might need to compare not only broadly different treatment options -- such as surgery vs. drug therapy -- but also different approaches to the same basic treatment -- such as different levels of follow-up care after surgery.

Studies that included an analysis of cost-effectiveness would probably have a larger impact than ones that compared only clinical effectiveness, because they would highlight cases where more expensive treatments or approaches provided added benefits that were modest compared with their added costs (at least for some types of patients).

(GAO, 2007) It is reported by the Governmental Accounting Office that in order to affect medical treatment and reduce spending on health care, the findings of comparative effectiveness analyses would "have to be persuasive" and additionally "would have to be used in ways that changed the behavior or doctors, other health professionals, and patients." (GAO, 2007) These types of significant changes in health care delivery would be controversial in that in order to develop a new system of incentives that were geared toward discouraging the use of the more expensive treatment with no or very little in the way of additional benefits the effectiveness study results would have to be strong enough to withstand scrutiny in ignoring the subgroups of patients who would derive great benefits from a treatment.

According to the GAO, report "Even with an expanded evidence base, some patients and providers might object to the use of such incentives, and keeping pace with new treatments and procedures would be an ongoing challenge." (GAO, 2007) The generation of more information regarding "comparative effectiveness" and then bringing about changes to reduce health care costs significantly is dependent upon various factors however, with the time it would take to go about the research and then develop new incentives to reflect the findings in addition to affecting behavior through those changes would require at least ten years and probably more to effect.

IV. Selection of Criteria The criteria selected in this review were the outcomes of any solutions posited for reducing health care costs. As well, criteria include the.