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PART V
Where Do We Go From Here?
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24
The Need for Reasonable Expectations
Henry ]. Aaron
I should like to begin by posing a question. Then, I shall simply take a
couple of points and beat the living daylights out of them.
Suppose one were given a multiple choice question, a very easy one with
only two alternatives. The question reads as follows: "This conference and
the work that preceded it have occurred because (a) key decision makers
have become devoted to the improvement of knowledge about the linkage
between medical interventions and medical outcomes OR (b) key decision
makers have become persuaded that many medical interventions are useless
and that effectiveness studies will document ineffectiveness and sharply
lower medical expenditures."
The best answer to that question is "Both." But if one were forced, in
the fashion of the Educational Testing Service, to choose the better answer,
it would have to be b.
Most people involved in effectiveness and outcomes studies were drawn
by scientific curiosity, unsullied by great concern about the cost issues.
They want to see improved medical care and effective use of resources to
promote improved health. In fact, many have been voices crying in the
wilderness on this issue for years, if not decades. Others are relative new-
comers, drawn into the field of effectiveness analysis by funding for it,
which is newly abundant and may, if Senator Rockefeller gets his wish
become still more abundant in the future (1~.
But my question was framed in terms of why the conference occurred
and the work that preceded it occurred.
The problem of effectiveness in medical care has been around for a very
long time. And despite the need for care in framing questions and in
thinking about how they should be posed to patients and providers, the
techniques involved in carrying out effectiveness research have, by and
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216
EFFECTIVENESS AND OUTCOMES IN HEALTH CARE
large, also been around for a very long time. So I think one has to ask why
the push for effectiveness research is coming only now.
The answer to that question, I think, is that the people who determine
budgets in Congress, in the executive branch, and perhaps even, to some
degree, in foundations think that the studies of effectiveness will save a lot
of money and ameliorate or solve the vexing problem of rising medical
costs, and that such studies will thereby render unnecessary most of the
rather difficult choices that rising costs seem to pose for the general population.
THE LIKELIHOOD OF UNMET EXPECTATIONS
The theme of my remarks is that this expectation is almost certain to be
frustrated and that the hope of avoiding the difficult questions is almost
certain to be disappointed. If I am right, we face some very difficult prob-
lems involving what to do if the results of effectiveness studies, on balance,
would boost rather than cut costs.
The first point I would stress is that a clearly defined, precise benefits
curve such as the one Uwe Reinhardt lays out (2) is not really the right way
to envision the problem. In fact, in the minds of individual practitioners
that curve is a wide range of very fuzzy curves. Furthermore, those curves
are not lines at all; rather they are shadowy expanses along which benefits
rise as the intensity of care increases, until they reach some point beyond
which they turn down. The point at which they turn down is a matter about
which disagreement is widespread, deep, and passionate.
The aim of effectiveness research, of course, is to convert those shadowy
blobs into something that looks more like a line. That process will lead, in
some cases, to less care, in other cases to more care, and probably in a large
number of cases to different care that may be roughly as costly as what we
have now.
From the other chapters in this volume, I glean exactly the answer I
expected to the question of whether implementation of the results of effec-
tiveness studies would raise or lower costs: No one is really quite sure.
"Some things will go up; some things will probably go down; we have to
run the numbers to find out. And even then we may not be sure because the
studies now under way include only a tiny part of the universe of possible
studies."
The second reason I think expectations are bound to be disappointed is
that, even if the direct result of effectiveness research is to save money on
certain forms of care, the net saving will be reduced by the cost of the
additional therapies that would prove necessary, either currently or at some
time in the future. To illustrate the difficulty of deciding whether something
reduces costs or not, consider the case of antibiotics. Did they by and large
reduce or increase the cost of medical care? The initial response, of course,
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WHERE DO WE GO FROM lIERE?
217
is that they reduced costs. The correct answer, I think, is that they in-
creased costs enormously by extending lives and enabling people to become
ill from much more costly diseases at some time in the future.
A third reason that hopes for savings will be disappointed involves time.
Effectiveness research will go on for decades. The results will accrue
slowly. Even if, on balance, the results achieve the cost reductions that the
most bullish supporters claim they will do, these results are going to come
in over a period so long that I would suggest they are going to be almost
undetectable against the background of other forces affecting medical care
expenditures.
WHAT EFFECTIVENESS RESEARCH CAN DO
All of this leads me to conclude that effectiveness analysis will and
should be expected to have no detectable effect on the rate at which health
care spending changes in the United States. It promises something far more
important than that, however: it promises improvements in the efficacy
with which we use medical care resources. It promises an improvement in
the quality of medical care.
I think the truth of the matter is that most of the people involved in the
Institute of Medicine's effectiveness effort are involved for the right reasons.
But the forces that led to the particular timing of this effort are predicated,
at least in some degree, on expectations that are going to be disappointed in
the future. If so, this disjunction between hope and reasonable expectation
raises an acutely difficult problem for persons who believe, correctly, that
effectiveness research is worth doing. If those persons tell funders what
they want to hear, they are going to be lying and the funders will find out
sooner or later. If those persons tell funders the truth, they risk cooling the
enthusiasm that makes the research possible.
The latter course is the one I think people are going to have to accept. I
must confess that I make this forecast hesitantly after all, persons who
advocate the former may have as much success as the advocates of compe-
tition have enjoyed, being able to live for years and years on unfulfilled
promises of cost reductions.
REFERENCES
1. Rockefeller, J. The Legislative Perspective. Pp. 44-48 in Effectiveness and
Outcomes in Health Care. Heithoff, K.A. and Lohr, K.N., eds. Washington, D.C.:
National Academy Press, 1990.
2. Reinhardt, U. The Social Perspective. Pp. 34-37 in Effectiveness and Outcomes in
Health Care. Heithoff, K.A. and Lohr, K.N. eds. Washington, D.C.: National Academy
Press, 1990.
