Peter Orszag is President Obama's Director of the Office of Management and Budget (OMB) and he has emerged as the architect of the fiscal aspects of healthcare reform. He is known as an expert on the concept of Comparative Effectiveness Research. This is simply a wonkish term for using best available evidence to guide decision making; in particular, using evidence based medicine to determine the most cost effective treatment guidelines (without sacrificing efficacy). For example, if the science demonstrates that generic pills are just as good as newer, more expensive combo-pills at controlling high blood pressure, then it would be reasonable to implement restrictions that would preclude physicians from prescribing the more expensive medication.
The Dartmouth Atlas Project, very much the hot new thing in the medical blogosphere this year, is a long term study of health care markets in the US measuring variations in health care resources and their utilization by geographic area. Basically, it showed that clinical outcomes are not necessarily related to the amount or cost of care provided, and that there is an incredible variation in practice patterns depending on what part of the country you examine. The message is clear: standardize the delivery of health care according to Comparative Effectiveness Research protocols and we can save boatloads of money in the health care sector. And this sort of thinking is Peter Orszag's baby. This is the underlying theory (along with redistribution of wealth) behind President Obama's health reform agenda. And it seems to have substantial validity.
But medicine doesn't like to be categorized. Although it would seem intuitive that we ought to always practice according to guidelines established by the "evidence", the reality is that we often go off the reservation in medicine. The history of medicine is full of doctors who went against the grain, despite available evidence, and ultimately ushered in new eras of innovation. The history of organ transplantation is absolutely fascinating. (Check out Joseph Murray's Nobel speech.) A small cadre of surgeons in the 1960's basically hammered out the principles of immunology and, through trial and error (and what was in essence human experimentation) were able to hone and standardize the transplant process over just a decade. Dr. Murray's first three kidney transplant patients (not including the initial transplants performed between identical twins) all died. By 1965, his group had achieved a 1 year allograft survival rate of 65%. Nowadays, there are people walking the streets with 30 and 40 year old donor kidneys. We are transplanting livers and pancreases and cataracts and lungs and even hearts. These pioneers were not guided by "best available evidence". It was completely ad libbed and improvised on the fly, until some modicum of success was attained and could be systematized.
Laparoscopy developed in a similar vein. There were no randomized controlled trials comparing open with laparoscopic cholecystectomy when the minimally invasive approach swept across this country in the early nineties. The data came later. The actual practice of surgery, however, developed independently of CER. Likewise, we don't currently have any level one evidence supporting laparoscopic appendectomy as being superior to open appy. But ask any general surgeon today and more and more are opting to treat appendicitis laparoscopically because of the superior wound infection rates, better cosmesis, faster recovery, and an increasing comfort level with performing the procedure itself. Eventually the "evidence" will confirm what is already apparent.
You see, medicine is a constantly evolving and developing field of science. Evidence based decision making is an excellent method to assess what has been done in the past, and help guide us through the complex process of deciding which treatment option is most prudent in terms of both cost and efficacy. But it doesn't help us figure out new paradigms for unforeseen challenges in health care. Innovation and risk-taking and aggressiveness are fundamental to advances in medical knowledge. We don't have a transplant program in this country if CER determined the allocation of funding in the 1960's. Laparoscopy was significantly more expensive in the early days of minimally invasive surgery because the equipment costs and length of OR time outweighed the benefits of a shorter hospital stay. Things have changed.
Let's just hope the brainy Peter Orszag has made allowances for innovation somewhere in his complex mathematical manipulations. The next quantum leap in medicine is always just around the corner; let's make sure that leap isn't hamstrung by too much government red tape and bureaucracy....