Some say stimulus boosts government role in health decisions

Washington -- A conservative backlash against comparative effectiveness research provisions in the stimulus package could be the first sign of a difficult health reform debate to come.

The stimulus act enacted Feb. 17 provides $1.1 billion to federal agencies for evaluations of the effectiveness of different drugs, devices and procedures on the same medical condition. The infusion is a huge increase over existing funding for comparative effectiveness research.

But the provision attracted unwanted attention as the stimulus bill moved forward. The House Appropriations Committee's summary of the version it approved on Jan. 15 said the bill would help determine which drugs, procedures and medical interventions are "less effective and in some cases, more expensive." Mentioning cost savings as a potential benefit of the research language was enough to lead conservative media outlets, from the Washington Times to radio host Rush Limbaugh, to conclude that an era of government-rationed health care was coming.

The speculation also was fueled by bill language creating a panel of federal government leaders to recommend federal priorities for comparative effectiveness research. A November 2008 white paper by Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, cited a Congressional Budget Office estimate that $700 billion of the nation's annual $2.3 trillion health spending is ineffective, said Dennis Smith, former director of the Centers for Medicare & Medicaid Services' Center for Medicaid and State Operations and a senior fellow at the Heritage Foundation.

Some GOP members of Congress, including Sen. Mike Enzi (R, Wyo.), spoke out against what was seen as a potential for additional government power over health spending. "The bureaucracy, not doctors and patients, will have the power to make decisions about which treatments folks can and can't have," Enzi said Feb. 13.

Robert Doherty, the American College of Physicians' senior vice president for governmental affairs and public policy, said some conservatives were looking far into the future when they objected to the act's research provisions. "This was viewed by some as the opening skirmish in a broader battle over the role of government in health care," Doherty said. The ACP and the American Medical Association supported the comparative effectiveness provisions and funding in the stimulus package, called the American Recovery and Reinvestment Act of 2009.

The final version of the bill did not specifically include cost as part of comparative effectiveness research. The House Appropriations panel's report summarizing the House-Senate negotiations that produced the final version said the research funding "is not to be used to mandate coverage, reimbursement or other policies for any public or private payer."

"There are a lot of dots [conservatives] are connecting. And the dots are certainly not connected in the bill," Doherty said.

Adding "clinical" to "comparative effectiveness" in the bill's language would have clarified that the research won't include costs as a factor, but the stimulus act didn't do that, said Gail Wilensky, PhD, a former Medicare administrator and senior fellow at Project Hope, an international health advocacy organization. "That is, in my mind, a permissive difference," she said.

Smith agreed on the need to compare treatments, but he worries about any payer, especially Medicare and Medicaid, having too much influence in the medical payment system.

Doherty said the concerns about government intrusion are overblown. "All it really does is provide additional funding to the National Institutes of Health and the Agency for Healthcare Research and Quality to build upon their existing work they are doing in comparative effectiveness."

Doctors and patients need more rigorous evidence about treatments' effectiveness, Doherty said. Informed patients might be more likely to choose a less-invasive treatment if its outcome is similar to surgery or another more invasive option.

Government funding of research isn't a perfect solution, said Roy Poses, MD, a clinical associate professor of internal medicine at Brown University in Rhode Island who has researched clinical epidemiology and evidence-based medicine. "But in the absence of research, the government might use something else to make coverage decisions that might be even less valid," he said.

Doherty said several ACP members contacted him after the association said it supported the stimulus bill, which was controversial among conservatives for a variety of reasons. "So it was hard to separate the health care provisions from one's overall views of the stimulus bill. For more conservative physicians ... a lot of them didn't like the idea of the stimulus bill, period."