NYT Editorial on 'Comparative Effective Research'

Epsilon Delta

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Jul 16, 2008
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Thought it was interesting and thought I'd share:

New York Times said:
The Value of Comparison
Published: May 16, 2011

Before you take a drug or undergo a medical procedure, wouldn’t you want to be sure it is the most effective and, if possible, the least costly available?

That is the idea behind so-called comparative effective research that is part of the health care reform law. Unfortunately, in the effort to win Republican support (support that never materialized), the bill’s sponsors agreed to bar Medicare from using comparative studies to determine which treatments to pay for. Critics charged it would mean more bureaucratic interference and a step toward socialized medicine.

The shortsightedness of that thinking was made clear last month when results were released of a government-sponsored study comparing two drug treatments for macular degeneration, which is the leading cause of vision loss and blindness in older Americans.

Both drugs are made by Genentech. Even so, there is a vast difference in their cost and, until now, uncertainty about their relative effectiveness.

[...]

Clinical trials sponsored by Genentech showed that Lucentis is highly effective in preserving and improving vision. The cost per monthly dose, however, was set by the company at $2,000. [...] Avastin can cost thousands of dollars a month for the quantities used to treat cancer, but the doses suitable for injection into the eye cost about $50 a month. [...] In 2008, Medicare paid for 480,000 injections of Avastin to treat macular degeneration — at a cost of $20 million. And it paid for 337,000 injections of Lucentis, at a cost of $537 million.

Until now, however, there was no scientific proof about whether Avastin was as effective as Lucentis. The National Eye Institute sponsored a two-year clinical trial whose first-year results were published in late April. It suggests that the cheaper Avastin is just as effective as Lucentis at preventing vision loss. More people taking Avastin were hospitalized, an adverse effect that needs further exploration, but there were no significant differences in the rate of deaths, heart attacks and strokes.

If these findings and the drug’s safety are confirmed in the second year, Medicare could save hundreds of millions of dollars annually if doctors used Avastin. But, as the system now works, Medicare cannot push doctors to switch. That means that taxpayers will likely continue to pay a lot more for a treatment that is no more effective. That makes no sense for anybody, except the drug maker.

http://www.nytimes.com/2011/05/17/opinion/17tue2.html?src=recg
 
Thought it was interesting and thought I'd share:

New York Times said:
The Value of Comparison
Published: May 16, 2011

Before you take a drug or undergo a medical procedure, wouldn’t you want to be sure it is the most effective and, if possible, the least costly available?

That is the idea behind so-called comparative effective research that is part of the health care reform law. Unfortunately, in the effort to win Republican support (support that never materialized), the bill’s sponsors agreed to bar Medicare from using comparative studies to determine which treatments to pay for. Critics charged it would mean more bureaucratic interference and a step toward socialized medicine.

The shortsightedness of that thinking was made clear last month when results were released of a government-sponsored study comparing two drug treatments for macular degeneration, which is the leading cause of vision loss and blindness in older Americans.

Both drugs are made by Genentech. Even so, there is a vast difference in their cost and, until now, uncertainty about their relative effectiveness.

[...]

Clinical trials sponsored by Genentech showed that Lucentis is highly effective in preserving and improving vision. The cost per monthly dose, however, was set by the company at $2,000. [...] Avastin can cost thousands of dollars a month for the quantities used to treat cancer, but the doses suitable for injection into the eye cost about $50 a month. [...] In 2008, Medicare paid for 480,000 injections of Avastin to treat macular degeneration — at a cost of $20 million. And it paid for 337,000 injections of Lucentis, at a cost of $537 million.

Until now, however, there was no scientific proof about whether Avastin was as effective as Lucentis. The National Eye Institute sponsored a two-year clinical trial whose first-year results were published in late April. It suggests that the cheaper Avastin is just as effective as Lucentis at preventing vision loss. More people taking Avastin were hospitalized, an adverse effect that needs further exploration, but there were no significant differences in the rate of deaths, heart attacks and strokes.

If these findings and the drug’s safety are confirmed in the second year, Medicare could save hundreds of millions of dollars annually if doctors used Avastin. But, as the system now works, Medicare cannot push doctors to switch. That means that taxpayers will likely continue to pay a lot more for a treatment that is no more effective. That makes no sense for anybody, except the drug maker.

http://www.nytimes.com/2011/05/17/opinion/17tue2.html?src=recg

Let me see if I get the gist of this.

Medicare should force patients to use a drug that, although is just as effective, it has more side effects and has runs a significant risk of hospitalization because, in the long run, it saves money. Isn't the NYT the same paper that harped on Palin's "death panel" characterization of this provision? Why is taking the decision out of the hands of doctors and patients a good idea?
 
Wait a second. Try it like this...

"Before you (insert any economic activity), wouldn’t you want to be sure it is the most effective and, if possible, the least costly available?"

Uh huh...it's called "Shopping"
 
Let me see if I get the gist of this.

Medicare should force patients to use a drug that, although is just as effective, it has more side effects and has runs a significant risk of hospitalization because, in the long run, it saves money. Isn't the NYT the same paper that harped on Palin's "death panel" characterization of this provision? Why is taking the decision out of the hands of doctors and patients a good idea?

No, you misunderstood the gist of it, specifically the part that states that there was no evidence that the expensive drug was any more effective than the cheap one. A two-year trial did not find that the expensive medicine was more effective (the causes for extra hospitalization were not made clear, it could have had no relation to the drugs at all). The article stresses that the finding's of the second year and product safety tests are further required.

The point is that even if both drugs are equally effective and contain no more side-effects than one another, Pharmaceutical companies can encourage and incentivize doctors to prescribe the more expensive one, while Medicare cannot do the same for the cheap one - even if it were just as good. This is what doesn't make any sense, they're using this one example to show it - it could well occur that the second year tests are horrible and the cheap drug is unusable, at which point it shouldn't be prescribed at all. But the same could happen with any other set of drugs.
 
No two drugs are exactly the same. Whether one outperformed another in a trial of 100 or 1000 or 10k people is largely irrelevant to whether the physician feels this patient would benefit from one or the other.

Again, a big gov't bureaucracy dictating individual health care decisions will result in a much worse quality of care. Just what the Dems want.
This is because their health care plan calls for reducing expenses. The only way to do that is to kill more people, leaving resources for others.
IOW the Dem plan is "they want you to die. Now."
 
Let me see if I get the gist of this.

Medicare should force patients to use a drug that, although is just as effective, it has more side effects and has runs a significant risk of hospitalization because, in the long run, it saves money. Isn't the NYT the same paper that harped on Palin's "death panel" characterization of this provision? Why is taking the decision out of the hands of doctors and patients a good idea?

No, you misunderstood the gist of it, specifically the part that states that there was no evidence that the expensive drug was any more effective than the cheap one. A two-year trial did not find that the expensive medicine was more effective (the causes for extra hospitalization were not made clear, it could have had no relation to the drugs at all). The article stresses that the finding's of the second year and product safety tests are further required.

The point is that even if both drugs are equally effective and contain no more side-effects than one another, Pharmaceutical companies can encourage and incentivize doctors to prescribe the more expensive one, while Medicare cannot do the same for the cheap one - even if it were just as good. This is what doesn't make any sense, they're using this one example to show it - it could well occur that the second year tests are horrible and the cheap drug is unusable, at which point it shouldn't be prescribed at all. But the same could happen with any other set of drugs.

Funny, this is from your post.

More people taking Avastin were hospitalized, an adverse effect that needs further exploration,

That sounds to me like there are more side effects, but maybe I just don't have the progressive mindset that thinks side effects don't count if the NYT says they don't.
 
Funny, this is from your post.

More people taking Avastin were hospitalized, an adverse effect that needs further exploration,

That sounds to me like there are more side effects, but maybe I just don't have the progressive mindset that thinks side effects don't count if the NYT says they don't.

Again, let me acquaint you with the word example:

Dictionary said:
ex·am·ple   
[ig-zam-puhl, -zahm-] Show IPA
noun, verb, -pled, -pling.
–noun
1.
one of a number of things, or a part of something, taken to show the character of the whole: This painting is an example of his early work.
2.
a pattern or model, as of something to be imitated or avoided: to set a good example.
3.
an instance serving for illustration; specimen: The case histories gave carefully detailed examples of this disease.

The Avastin vs. Lucentis case is an example. The article is not endorsing one or another of these products. It's illustrating that, if your tax-funded Medicare program has access to two types of medication and both are proven to be equally safe and effective, that Medicare cannot favor the cheaper medicine. In regards to this particular case there are two potential future scenarios:

1. The second year trial comes back, hospitalization rates are linked to Avastin use. Avastin is shown to be more worse than Lucentis, Medicare has no reason to and shouldn't encourage use of Avastin.
2. The second year trial comes back, hospitalization rates are not linked to Avastin use. Avastin is shown to be equal in safety and efficiency as Lucentis, yet tax-funded, deficit-driving Medicare cannot encourage its doctors to switch. Assuming this is true, why shouldn't they be able to?

Taking the example out and making it a more general case, think of it this way: Assuming Med X treats the same ailments as Med Y, and both are clinically shown to be of equal efficiency and safety with the only difference being that Med X is twice as expensive as Med Y, why should the tax-funded, deficit-driving government healthcare provider not encourage the use of the cheaper medicine? That is the question that has to be answered.

TheRabbi said:
No two drugs are exactly the same. Whether one outperformed another in a trial of 100 or 1000 or 10k people is largely irrelevant to whether the physician feels this patient would benefit from one or the other.

Again, a big gov't bureaucracy dictating individual health care decisions will result in a much worse quality of care. Just what the Dems want.
This is because their health care plan calls for reducing expenses. The only way to do that is to kill more people, leaving resources for others.
IOW the Dem plan is "they want you to die. Now."

You don't think that if a drug outperformed another drug that this would not have some impact on which drug the doctor feels would be most beneficial for a patient? One would certainly hope it does, but that's not whatsoever what the article is about anyway. The fact is that Pharmaceutical Companies (as Genentech did in this example by offering rebates to doctors) are able to encourage doctors to use one medicine over another [ie, the more expensive one].

Doctors are not superhuman. They react to incentives just like everybody else. The point here is that private phamaceutical co's can incentivize doctors to pick more expensive medicine, but your tax-funded, deficit-driving Medicare can't incentivize them to pick the cheaper medicine. You seem rightfully concerned about "Big Gov't!" dictating health care, but you seem perfectly fine with allowing "Big Pharma" to do the same. I say, let them balance each other out at least.
 
Except that the very case they use as an example has worse side effects.

Personally, I always opt for the generic, but they always have more side effects, and are usually less efficacious. A panel of doctors who have not met me, or the person who is more drug sensitive, should not be making that decision.

That is the entire argument. Post all the examples you want, what actually matters is the individual taking the drugs.
 
Except that the very case they use as an example has worse side effects.

Personally, I always opt for the generic, but they always have more side effects, and are usually less efficacious. A panel of doctors who have not met me, or the person who is more drug sensitive, should not be making that decision.

That is the entire argument. Post all the examples you want, what actually matters is the individual taking the drugs.

1. Not really, nobody can possibly know that until the full clinical trial is published.

2. I don't think you understand. The problem are not over-the-counter medicines that you decide to buy. This entire issue is about prescription drugs. You can talk all you want about the "rugged individual with his personal choice," but such a concept is entirely absent in this issue, because most people don't know fuck-all about particular medicines. 99% of people who are prescribed a drug by their doctor will take that drug. I, for one, don't think it's too far-fetched to believe that a doctor is more qualified than I am to decide which of two obscure medications for a particular ailment is better. The problem arises from the fact that doctors are being incentivized by drug companies to sell more expensive drugs.

Using the general example again, the doctor has a handful of options for what to prescribe, two being Med X and Med Y. He makes this choice FOR YOU - YOU don't make the choice. There IS no "personal choice" matter here. He knows both work just as well as one another, but PharmaCo corporation is going to give him a rebate for prescribing Med X so he will most likely do so, because fuck it, he knows it still works and he's going to get payed more. This becomes a social issue because of the existence of Medicare, which YOUR taxes fund. So in effect, the point here is that a decision by business executives (whose aims are to make more money, because that's what corporations do, and there's nothing wrong with that in particular) will hold sway over the person who makes these decisions for you - your doctor. At the same time, Medicare (whose aims are to control costs so that Congressmen stop screaming over the deficit and the country goes bankrupt, nothing particularly wrong with that either) is being barred from holding sway. The result? Medical costs in the United States have been and will continue to spin out of control and the problem is no longer about "the individual taking the drugs" exclusively.
 
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TheRabbi said:
No two drugs are exactly the same. Whether one outperformed another in a trial of 100 or 1000 or 10k people is largely irrelevant to whether the physician feels this patient would benefit from one or the other.

Again, a big gov't bureaucracy dictating individual health care decisions will result in a much worse quality of care. Just what the Dems want.
This is because their health care plan calls for reducing expenses. The only way to do that is to kill more people, leaving resources for others.
IOW the Dem plan is "they want you to die. Now."

You don't think that if a drug outperformed another drug that this would not have some impact on which drug the doctor feels would be most beneficial for a patient? One would certainly hope it does, but that's not whatsoever what the article is about anyway. The fact is that Pharmaceutical Companies (as Genentech did in this example by offering rebates to doctors) are able to encourage doctors to use one medicine over another [ie, the more expensive one].

Doctors are not superhuman. They react to incentives just like everybody else. The point here is that private phamaceutical co's can incentivize doctors to pick more expensive medicine, but your tax-funded, deficit-driving Medicare can't incentivize them to pick the cheaper medicine. You seem rightfully concerned about "Big Gov't!" dictating health care, but you seem perfectly fine with allowing "Big Pharma" to do the same. I say, let them balance each other out at least.

I dont know that anyone has shown that offering rebates or other incentives to doctors influences them to write a prescription for one drug or another.
It's of course more complicated than you lay out. My two older brothers are doctors and I recall some incident about this where a cheaper less effective drug would have worked fine for this patient but Medicare wouldn't cover it.
In any case I don't want Medicare dictating which drugs my doc can and cannot prescribe. If my doc prescribes the wrong one I can find another doctor or sue him. What do I do with Medicare?
 
Why should the government have anything to do with a persons health care in the first place?

Oh...yeah...I forgot. The Nanny State Syndrome.

The Soviets tried that...and people fled in droves...unless they were shot first.
 
I dont know that anyone has shown that offering rebates or other incentives to doctors influences them to write a prescription for one drug or another.
It's of course more complicated than you lay out. My two older brothers are doctors and I recall some incident about this where a cheaper less effective drug would have worked fine for this patient but Medicare wouldn't cover it.

Well, I lay it out in the above post responding to QW: The doctor has a choice between the cheaper med and the expensive med, both equal, but he gets more money if the expensive one is prescribed. It's not that they're evil or screwing with the patient (both medicines work fine), but the tab gets picked up by the government (ie, the tax-payer) and paid to the company.

In any case I don't want Medicare dictating which drugs my doc can and cannot prescribe. If my doc prescribes the wrong one I can find another doctor or sue him. What do I do with Medicare?

But remember that what I'm talking about here is not doctors prescribing the wrong medication, but rather prescribing a more expensive medication due to incentives provided by "big Pharma." The cost is not passed on to the consumer but the government (ie, the tax-payer) [because we're also talking here exclusively about people covered by Medicaid and Medicare].

Why shouldn't Medicare also encourage doctors to buy the cheaper medication, if and when both medications are proven to be just as effective (this being an important caveat), especially when such a thing would help control medical costs which in turn are virtually the largest projected chunk of the federal deficit? I'm certain that's exactly what private insurers do if they have to pick up the cost of more expensive medication (so long as they're not themselves owned by a Pharmaceutical company) - they cut costs. Is that not what a healthy business does?
 
Why should the government have anything to do with a persons health care in the first place?

Oh...yeah...I forgot. The Nanny State Syndrome.

The Soviets tried that...and people fled in droves...unless they were shot first.

Did it occur to you that people were fleeing in droves not because of health care but because of the pervasive surveillance and brutal repression employed by the Soviet regime?

Because now that you mention fleeing in droves and health care, it is quite interesting to note that most third world countries have no "socialized" medicine and cannot cover most of their populations in the health care schemes, yet most of these people are fleeing towards Industrial countries where the opposite is true and there is universal government health care (the US being a notable exception).

Hmmm...
 
Except that the very case they use as an example has worse side effects.

Personally, I always opt for the generic, but they always have more side effects, and are usually less efficacious. A panel of doctors who have not met me, or the person who is more drug sensitive, should not be making that decision.

That is the entire argument. Post all the examples you want, what actually matters is the individual taking the drugs.

1. Not really, nobody can possibly know that until the full clinical trial is published.

2. I don't think you understand. The problem are not over-the-counter medicines that you decide to buy. This entire issue is about prescription drugs. You can talk all you want about the "rugged individual with his personal choice," but such a concept is entirely absent in this issue, because most people don't know fuck-all about particular medicines. 99% of people who are prescribed a drug by their doctor will take that drug. I, for one, don't think it's too far-fetched to believe that a doctor is more qualified than I am to decide which of two obscure medications for a particular ailment is better. The problem arises from the fact that doctors are being incentivized by drug companies to sell more expensive drugs.

Using the general example again, the doctor has a handful of options for what to prescribe, two being Med X and Med Y. He makes this choice FOR YOU - YOU don't make the choice. There IS no "personal choice" matter here. He knows both work just as well as one another, but PharmaCo corporation is going to give him a rebate for prescribing Med X so he will most likely do so, because fuck it, he knows it still works and he's going to get payed more. This becomes a social issue because of the existence of Medicare, which YOUR taxes fund. So in effect, the point here is that a decision by business executives (whose aims are to make more money, because that's what corporations do, and there's nothing wrong with that in particular) will hold sway over the person who makes these decisions for you - your doctor. At the same time, Medicare (whose aims are to control costs so that Congressmen stop screaming over the deficit and the country goes bankrupt, nothing particularly wrong with that either) is being barred from holding sway. The result? Medical costs in the United States have been and will continue to spin out of control and the problem is no longer about "the individual taking the drugs" exclusively.

I understand.

A lot of HMOs use generics because they are less expensive and just as effective in clinical trials. This often leads to less promising results in the real world. Many people complain about this policy, and liberals are quite vocal about it.

Now that Obama wants to turn Medicare into a giant HMO it is suddenly a good idea. Why is that?

As for the claim that doctors get money from prescribing more expensive meds, I have never run into it, and often bring up the cost of meds when discussion options. Not one of them has ever tried to make me take a more expensive med, probably because what you are describing is actually illegal.
 
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No two drugs are exactly the same. Whether one outperformed another in a trial of 100 or 1000 or 10k people is largely irrelevant to whether the physician feels this patient would benefit from one or the other.

Again, a big gov't bureaucracy dictating individual health care decisions will result in a much worse quality of care. Just what the Dems want.
This is because their health care plan calls for reducing expenses. The only way to do that is to kill more people, leaving resources for others.
IOW the Dem plan is "they want you to die. Now."

The truth about most drugs is that the doctors prescribing them really have no clue whether they are effective or not, especially newer drugs. They will prescribe one after another until they find one that may help the patient. Most doctors are receiving kickbacks in the form of trips and gifts to get them to prescribe certain drugs. The greater the bennies from the drug companies, the more they will prescribe that company's drug.

That is not to say that doctors never prescribe a necessary drug or that they are completely clueless. But this is how the game is played, and it's one of the reasons many people end up taking ten or twenty different drugs at a time, because each one brings with it some side effect, so another drug is prescribed to counter the side effect of the first drug. In the end, most people would be better off just staying away from them altogether.
 
I dont know that anyone has shown that offering rebates or other incentives to doctors influences them to write a prescription for one drug or another.
It's of course more complicated than you lay out. My two older brothers are doctors and I recall some incident about this where a cheaper less effective drug would have worked fine for this patient but Medicare wouldn't cover it.

Well, I lay it out in the above post responding to QW: The doctor has a choice between the cheaper med and the expensive med, both equal, but he gets more money if the expensive one is prescribed. It's not that they're evil or screwing with the patient (both medicines work fine), but the tab gets picked up by the government (ie, the tax-payer) and paid to the company.

In any case I don't want Medicare dictating which drugs my doc can and cannot prescribe. If my doc prescribes the wrong one I can find another doctor or sue him. What do I do with Medicare?

But remember that what I'm talking about here is not doctors prescribing the wrong medication, but rather prescribing a more expensive medication due to incentives provided by "big Pharma." The cost is not passed on to the consumer but the government (ie, the tax-payer) [because we're also talking here exclusively about people covered by Medicaid and Medicare].

Why shouldn't Medicare also encourage doctors to buy the cheaper medication, if and when both medications are proven to be just as effective (this being an important caveat), especially when such a thing would help control medical costs which in turn are virtually the largest projected chunk of the federal deficit? I'm certain that's exactly what private insurers do if they have to pick up the cost of more expensive medication (so long as they're not themselves owned by a Pharmaceutical company) - they cut costs. Is that not what a healthy business does?

First off, in my experience doctors don't have a clue which medicine is more or less expensive. They dont know what they cost.
Second, you make an assumption doctors are swayed by pharm marketing. There is no evidence I have seen to support that.
Third, you again miss the distinction: Medicare TELLS doctors what they may or may not do. Pharm companies suggest to doctors what to do. See the difference?
Finally, whatever a medication has been proven in some study is irrelevant to whether it will work better for this patient. Maybe the patient has a contra-indicator for the cheaper medicine. Maybe the doc's experience is that patients with this type of condition respond better to this one rather than that one. Whatever it is, I don't want some bureaucrat dictating what a doc may or may not do.
 
Wait a second. Try it like this...

"Before you (insert any economic activity), wouldn’t you want to be sure it is the most effective and, if possible, the least costly available?"

Uh huh...it's called "Shopping"

Indeed. Which is why (1) this is a common sense idea, and (2) it's a travesty that the evidence base on which one would rely in making these shopping decisions simply doesn't exist in many cases.

People ought to be able to make decisions based not only on cost but on an accurate assessment of the effectiveness of a treatment relative to alternative treatment options. But only recently has a concerted effort to build that research base been jump started. That's a step toward making shopping for health services a more realistic option.
 
Wait a second. Try it like this...

"Before you (insert any economic activity), wouldn’t you want to be sure it is the most effective and, if possible, the least costly available?"

Uh huh...it's called "Shopping"

Indeed. Which is why (1) this is a common sense idea, and (2) it's a travesty that the evidence base on which one would rely in making these shopping decisions simply doesn't exist in many cases.

People ought to be able to make decisions based not only on cost but on an accurate assessment of the effectiveness of a treatment relative to alternative treatment options. But only recently has a concerted effort to build that research base been jump started. That's a step toward making shopping for health services a more realistic option.

Government knows best, Dear. Let the government shop for you.
 
Government knows best, Dear. Let the government shop for you.

Fanserviceftw_7538_Obvious_troll_is_obvious.jpg
 

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