Tuesday, August 11, 2009

Questions for your health care town hall: Sec. 1401 and miscellany 

I am going to skip ahead in these notes. Diminishing returns set in; much of the middle third of H.R. 3200 are directives of what services get covered, who can provide, how much gets paid, etc. I'm not a health economist -- there are many portions of this review that I frankly prefer to outsource to economists like Keith Hennessey who has worked on this topic much longer. But I do want to say a few other things here and then review comparative effectiveness research.

A few preliminaries. First, I apologize for length. I did intentionally make yesterday's post long (over 1800 words) so you could see how dense and incomprehensible the language is. It's roughly 22 times the size of the U.S. Constitution. That should strike one as a warning. (It's also four times the size of the Patient's Choice Act; I wish the latter could be smaller.)
In the comments was reference to the home visitation section of the bill. In the middle of this was a reference that I want to highlight:
This is a statement that runs throughout the 1,100 pages and bothers me every time I see it:
(4) OTHER INFORMATION.�Such other information as the Secretary may require.
By my count, 13 times. I want to make sure you ask this question, and I will make it simple for those worried my questions are too long: Senator/Congressperson, what oversight does the Congress expect to have over decisions of the HHS secretary? Do you have any plans to put more oversight into the bill? Democrats, I expect, will answer yes. But this bill is not amendable into something good. So if you hear them say that, you know they aren't going to do the right thing, which is to kill this thing dead.

I'd also like to quickly dismiss the concern over Sec. 1233, which provides a monetary incentive for health care providers to offer people end-of-life counseling. I'd ask you this: Suppose it was your private insurance provider who was incentivizing the counseling. Would you object? I think it's hard for a doctor, trained to save lives, to talk about what happens when they decide you can't be saved. I'm going to go out on a limb -- you're welcome to saw it from under me -- to say this service is underprovided in the private sector. And yet there's an incentive problem at the end of life, both from legal liability and moral standpoints. This may be a place where Pigou is welcome.

OK, on to Sec. 1401, which adds to the Social Security Act:
Sec. 1181. (a) Center for Comparative Effectiveness Research Established-
`(1) IN GENERAL- The Secretary shall establish within the Agency for Healthcare Research and Quality a Center for Comparative Effectiveness Research (in this section referred to as the `Center') to conduct, support, and synthesize research (including research conducted or supported under section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003) with respect to the outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically.
`(2) DUTIES- The Center shall--
`(A) conduct, support, and synthesize research relevant to the comparative effectiveness of the full spectrum of health care items, services and systems, including pharmaceuticals, medical devices, medical and surgical procedures, and other medical interventions;
`(B) conduct and support systematic reviews of clinical research, including original research conducted subsequent to the date of the enactment of this section;
`(C) continuously develop rigorous scientific methodologies for conducting comparative effectiveness studies, and use such methodologies appropriately;
`(D) submit to the Comparative Effectiveness Research Commission, the Secretary, and Congress appropriate relevant reports described in subsection (d)(2); and
`(E) encourage, as appropriate, the development and use of clinical registries and the development of clinical effectiveness research data networks from electronic health records, post marketing drug and medical device surveillance efforts, and other forms of electronic health data.
It runs on for pages defining an oversight committee, composition of the committee, terms and compensation, etc. The oversight committee, called the "Comparative Effectiveness Research Commission" will disseminate "the findings of research conducted and supported under this section that enables clinicians, patients, consumers, and payers to make more informed health care decisions that improve quality and value." That "and payers" part I emphasized because that includes the government and its new Health Choices Administration.

So some questions for your senator or congressperson:
  1. What will you do with the results of the Comparative Effectiveness Research Commission?
  2. Will these results be used in redefining the qualified insurance package I can get? That is, suppose my insurer looks at those results and doesn't change funding for certain treatments. Will the government make them do so?
  3. There are private groups doing comparative effectiveness research. Insurers no doubt do much of this. Why do we need a government agency to do it? Is this a good use of our money?
  4. Relatedly, wasn't there a billion spent on this in the stimulus act?
  5. To what extent will the commission consider cost in its analysis? Uwe Reinhardt, an advisor during the Hillarycare debate, wrings his hands over people spending too much on their health care. Do you worry about this?
  6. Do you have any evidence that this will save money? CBO says not before 2019.
I may have one more of these in me; there is the "waste, fraud and abuse" parts of the act that I find humorous, actually. But you should have plenty of questions to ask now that are specific. If you want any more, Sen Tom Coburn has ten more.

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