professionals to adopt evidence-based practices, as well. In such a potentially contentious arena, the analyses that support coverage decisions must be absolutely independent, methodologically sound, and perfectly transparent.

Although information is rarely perfect and controversies may arise, in the long run it seems fundamental that payers should reward care for which there is evidence of value and discourage care that is either too costly for the benefit received or too low in benefit, regardless of cost. At present, the science is far from able to translate this general principle into care decisions for individual patients with their unique needs; nor would an absolute application of general rules to individual cases be ethically acceptable.

To take full advantage of the findings from effectiveness research, CMS reimbursement practices will have to change. With new and better information from these analyses, CMS should be able to focus on creating value in the system, by developing a range of policy incentives for

  • better management of high-cost chronic illnesses, including proactive management by providers and self-management by patients (practices discouraged by some current reimbursement policies);

  • use of primary, versus specialist, care;

  • reduced geographic variation in care patterns;

  • better integration of care, through, for example, establishment of a medical home or similar mechanism for assuring continuous, accessible, comprehensive, and coordinated care; and

  • more efficient practices, generally, including adoption of electronic information exchange and clinical records.

Comparative effectiveness research, like any sharp tool, needs to be used carefully. It does not provide the answer to every question. Most thought leaders acknowledge that it can reduce uncertainty, but there will rarely be black-and-white choices that can guide coverage decisions. In other words, when it comes to care for individual patients, we must accept a gray area. However, this type of research would provide information that patients and physicians need to make choices that offer them the greatest value, as they define it.

The committee believes strongly that the department’s activities must rest on a strong science base, that it should foster ongoing learning



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