Obamacare’s Rationers Employ The “It’s Good For You” Defense

Obamacare’s backers have a plan to justify their attempts to ration medicine — by saying that it’s good for you.

Through 2019, the Patient Protection and Affordable Care Act — otherwise known as Obamacare — will allocate some $3.5 billion toward “Comparative Effectiveness Research,” or CER, which pits drug versus drug in tests intended to determine which treatments work best.

CER advocates say that it’s designed to correct a “market failure.” Right now, they argue, drug firms need not demonstrate that their product is better than those already on the market — only that it is effective at treating the disease it targets. Drug companies have little incentive to compare their products to those made by other firms — as they may not come out on top.

CER sounds innocuous enough. Who could be against research to help doctors make more informed decisions?

But the truth is that CER is nothing more than a backdoor route to healthcare rationing. Such research will almost certainly be used to not-so-subtly influence treatment decisions.

To run its CER efforts, Obamacare establishes a “Patient-Centered Outcomes Research Institute” (PCORI) — a public-private entity that oversees the law’s funding, goals, and outside partnerships.

Technically, PCORI isn’t allowed to “dictate” coverage mandates or reimbursement levels based on its findings. But that doesn’t mean that private insurers or public payers like Medicare and Medicaid can’t use the center’s findings to adjust coverage and reimbursement decisions accordingly.

Indeed, Obamacare explicitly says that it should “not be construed as preventing the Secretary from using evidence or findings from such comparative clinical effectiveness research in determining coverage, reimbursement, or incentive program.”

That’s exactly what CER advocates hope Medicare will do. Researchers from the Institute for Clinical and Economic Review in Boston and New York‘s Sloan-Kettering Cancer Center have both argued as much in the pages of the influential health policy journal Health Affairs.

In October 2010, just months after Obamacare passed, the journal published a paper arguing that “in spite of substantial political hurdles,” efforts should be made to change Medicare’s reimbursement system so that it pays based on new CER findings. Under the proposed scheme, drugs recommended by the PCORI, could be reimbursed at higher rates. Others would get lower payments. Doctors would effectively have a big financial incentive to avoid drugs that don’t get the PCORI stamp of approval.

The overall goal, the researchers said, would be to “place Medicare on a more sustainable financial footing.”

So despite the technical prohibition against making coverage decisions or changing reimbursement levels, PCORI’s CER findings are likely to have a huge effect on what treatments are actually available to the public.

And that should scare patients and doctors alike.

For starters, doctors don’t always agree on what comparative-effectiveness research is actually telling us. As the RAND Corporation recently reported, “there’s generally not a shared understanding of the findings from this research.”

Further, what works well for one patient might not for another. CER leaves little room for differences among individuals — and instead elevates a hypothetical, “average” patient.

We’ve already seen how this goes, and the results aren’t pretty. Back in 2009, the U.S. Preventive Services Task Force — another government-run panel of independent experts — revised its breast-cancer screening recommendations by telling women to wait until age 50 before undergoing routine mammograms. Previously, the group had encouraged women to start mammograms at age 40.

One reason the Task Force cited for the change? Cost.

Only after a public outcry did Health and Human Services Secretary Kathleen Sebelius make clear that her agency would not support the recommendations.

Controversies like these are becoming more common. For instance, the American Association of Pediatrics recently changed its recommendations for the treatment of respiratory syncytial virus (RSV), a potentially deadly respiratory infection that afflicts half of all infants during their first year of life — and almost all by the end of year two.

The AAP shrank the pool of infants deemed at risk for RSV and lowered the maximum time for treatment from five months to three. Nevermind that no study had verified the efficacy of a three-month dosing regimen, in contrast to the proven five-month program. The AAP’s justification for the change? “To ensure optimal balance of benefit and cost.”

That’s the sort of decision that individual doctors and patients should make — not cost-conscious technocrats.

At its best, comparative-effectiveness research can give doctors and patients additional information on their treatment options. But when that research crosses into the realm of cost-effectiveness, patients suffer.

Unfortunately, that’s exactly where Obamacare’s CER push intends to take us.