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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 215

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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.