Surprising resistance to the embrace of evidence-based medicine as part of health reform reflects a fear of binary and bureaucratic government regulations that ignore the dynamic nature of science. Some of these objections are defensive, but they nonetheless deserve a respectful and honest response, lest they fester to a point where they jeopardize progress.
I've encountered three separate expressions of concern. The first was from conservative elements cable news/blogosphere community which predictably warned that the government was going to come between patients and their doctors and second-guess therapeutic decisions in an effort to save money. The others came from physicians. One is a psychiatrist who argues that every patient is unique and merits a unique response. The other argued that there's a danger research results will be imposed too widely as results are taken too seriously too soon and thus fuel today's escalation of ineffective and expensive care.
These arguments have merit, particularly if we're truly moving toward a government-written rule-based cookbook that draws crude, bright lines that will only allow women over 47 to get a mammogram irrespective of personal circumstances. It isn't clear whether any of the reformers truly want to go there. Doing so would be a mistake.
But adopting the pluralism that governs other elements of our political life seems sensible. We license drugs, but allow providers to select which is most appropriate for a particular situation.
As economist and budget expert Alice Rivlin recently noted, we need a way to sensibly limit treatment options - an absolute necessity if we're to squeeze out the estimated 30 percent of treatment dollars that are wasted - without being unduly restrictive.
A recent article in the New York Times documented our addiction to unproven treatments, citing evidence that standard treatments for heart attacks, osteoarthritis and ear infections simply don't work and can cause harm to patients.
Why do we continue to push hospitals to administer beta blockers to heart attack victims when the studies show - by a score of 26-2 - that it doesn't do any good?
Why do a half million Americans get knee surgery every year - at a cost of $3 billion - for a problem that the surgery apparently doesn't help? Patients subjected to sham surgery are just as happy with the result.
Why do a similar number get back surgery - which costs $20 billion - when non-surgical therapies do an equally effective job of reducing pain? Such questions posed by reformers demand answers.
Spending money on efficacy research isn't a good investment if the results have no impact. Imposing rigid rules based on such research doesn't make sense either. It isn't good politics or good science, both of which are fluid and change over time.
This point was driven home in a recent blog where the Mayo Clinic, widely perceived as efficient and evidence-based, was criticized because of a failure to embrace procedures that another health system had deemed evidence-based. Implied was a Gold Standard of Evidence that everyone would follow - at least until it changed, which happens quite frequently on issues ranging from estrogen replacement to PSA screening to mammograms to use of statins.
The fact that Kaiser and the VA and Mayo come up with slightly different results based on the way they screen the evidence doesn't trouble me. What's troubling is that many providers are not using similar scientific techniques to screen what works. So they continue to prescribe antibiotics for ear infections, ignoring evidence that they're more likely to harm than help.
Conservatives who want to maximize personal - and provider - freedom tend to argue that transparency is the answer. Make the research available to all and let the people decide. But the people lack the sophistication to decide. That's why we rely on medical professionals with expertise. If we patients were able to make competent decisions, the unemployment rate among physicians would soar. That won't happen anytime soon.
There seems to be a broad consensus that the current policy where virtually anything goes - and is reimbursed - isn't working well. In a culture where more is often seen as better, encouraging patients to push their providers toward less expansive remedies is an uphill sell. That explains part of the negative reaction to managed care. The issue here is how to impose sensible parameters on care that patients will not only accept, but derive a certain comfort from.
Finding a middle way - which is the hallmark of our political system - where providers rely on evidence that guides them among viable options without being unduly restrictive, will be a major challenge as the process moves forward.