Healthcare Reform and Evidence-Based Medicine – Do They Intersect?
Is the government’s current approach supported by the data?
By Jay I. Pomerantz, MD – Senior Physician Advisor for Health Integrated
After reviewing both the House bill[1] and the recently announced Senate bill, it would appear that healthcare reform is in process. Although there are some seemingly good aspects to both bills, as we have discussed in previous posts, there is still so much that needs to be addressed. To me, some of the burning issues include the redesign of the care delivery model, improving outcomes, addressing the increasing number of people being covered, overall reduction in cost without affecting outcome (and in fact trying to improve outcomes) and countless other key issues. The one area that could use more focus is evidence-based medicine.
Both the House and the Senate bills reference evidence-based medicine (EBM) 26 and 24 times respectively. As well, they reference evidence-based ‘prevention’. It is encouraging to see that in these bills, evidence-based procedures – both current and future, are encouraged and supported. There are ‘grant’ monies available for evidence-based models and other innovative approaches. More on these grant monies in a minute. My concern is that although EBM is ‘mentioned’, it is not detailed or defined and hence it would seem still subject to interpretation. There is however, in section 4105 [2] titled, “Evidence-Based Coverage of Preventive Services in Medicare”, a clause which states that there is authority to modify or eliminate coverage of certain preventive services, the Secretary may – “…modify the coverage of any preventive service… [so that it is] consistent with the recommendations of the United States Preventive Services Task Force…” Interesting…
Most recently, the announcement by the U.S. Preventive Services Task Force (USPSTF) two weeks ago focused on mammograms – their commencement and frequency, which caused quite a stir. The new ‘recommendation’ suggests that routine screening mammograms be performed every 2 years beginning at age 50 and ending by age 74, based on the existing clinical evidence. In their review, the task force also indicated that although breast self exams have been promoted for years, for the physician-driven education of these, there is now “…good evidence to show that they don’t help save lives…” Many statistics are quoted, many ‘evidence-based’. The task force further quotes the Dana-Farber Cancer Institute when asked about whether mammograms reduce women’s risk of dying from breast cancer – it may reduce this risk by 15% for women in their 40s and 50s, but their absolute benefit for younger women is much smaller. Making that tiny risk even smaller doesn’t prevent many deaths. They further go on to say that doctors would have to screen 1904 women ages 39 – 49 for a decade to prevent one death, vs. 1339 women 50 – 59 and 377 women 60 – 69 according to a study accompanying the recommendations (Annals of Internal Medicine). Mmm, really makes you think.
So although HHS Secretary Kathleen Sebelius reiterated that the federal policy regarding breast cancer screening has not changed, the government adopted a very active role in this discussion, AND based on the Senate’s version of the bill, they have full discretion to enact any coverage policy based on the recommendation of the USPSTF. If the government gets this involved at this early stage of the healthcare reform debate, before they have passed and subsequently implemented their version of healthcare reform, it would seem that the announcement may be as much about testing American’s tolerance of government meddle in personal healthcare decisions. What is interesting is that we know that the Task Force is not new, nor are the recommendations made by them done haphazardly. Some also postulate that it is possible that this announcement is further a thinly-veiled trial balloon about cost reduction versus actually improving outcomes, or minimally keeping them the same?
An additional yet less-obvious facet to the issue may not be whether the evidence supports better outcomes or not. Using mammograms as one of the most personal of examples, an individual’s decision to screen or not may be as much about gaining peace of mind as it is about outcomes. Although the data may support that only one in 1,904 women between 39 and 49 would be at risk of dying, this is one life that is saved, and if you are that ‘one’ person, it would seem to be pretty important. Where might the line be drawn on what constitutes an acceptable recommendation?
All of that said, this announcement should not dilute or stop the discussions about EBM and how critical it is. If anything, it should accelerate them. As more and more research becomes available, it continues to be critical that the clinician use the best evidence available, in consultation with the patient, to decide upon which option best suits that patient. Additionally, as the breast cancer screening discussion has uncovered, additional qualified experts should be tapped so that the most complete ‘evidence’ is available for review, analysis and conclusion. (e.g. organizations like ACOG and The American College of Radiology were not included in either the review of available studies or the crafting of the recommendation and hence rejected the committee’s conclusions. Top healthcare facilities like The Mayo Clinic publically rejected the claims as well.)
Additionally, like the recommendations for PCMH within both the House and Senate bills, there is a push to continue to study. Most of the evidence-based language deals with grants to further study, the criteria of what to study and how to study it, not yet determined. If and when these studies actually commence, the recommendations won’t be forthcoming until after 2013, if then. Some of the high-level recommendations seem sound – reviewing evidence-based approaches for chronic ailments, but it seems that we already know enough to get started and thus by implementing now, can accelerate both the medical and financial benefits now rather than waiting.
What do you think?
Thank you for taking the time to read, comment and forward. I have referenced some additional resources regarding evidence-based medicine for your review. You are welcome to contact me directly at pcmhdialog@healthintegrated.com. As always, I have listed some future topics in which I would welcome your review and comments.
Best Regards,
Jay I. Pomerantz, MD
Upcoming topics for the Health Integrated PCMH Collaborative Community
- Healthcare reform and the PCMH – the continuing review and update
- Standards for PCMH pilots and programs – how to establish a program
- Examples of ongoing PCMHs
- PCMH and healthcare disparities
- Expense consolidation for the PCMH
- Others?
Some other resources on Evidence-Based Medicine:
Journal of Evidence-Based Medicine (JEBM): http://www.wiley.com/bw/journal.asp?ref=1756-5383
American College of Physicians (ACP): http://www.acponline.org/?jchp
ACP Journal Club (ACPJC): http://www.acpjc.org/index.html
Pediatric Critical Care Medicine (PCCM): http://pedsccm.org/EBJournal_Resources.php
University of IL, Chicago: http://www.uic.edu/depts/lib/lhsp/resources/publ.shtml
National Registry of Evidence-Based Programs and Practices (NREPP): http://www.nrepp.samhsa.gov/
The Cochrane Collaboration: http://www.cochrane.org/docs/descrip.htm
Evidence-based medicine – UK (BMJ): http://ebm.bmj.com/
Evidence-Based Practice (from editors of the Journal of Family Practice): www.ebponline.net
[1] H.R. 3962
[2] Senate Bill, page 1189, section 4105,n)1)A), lines 17 – 22
