And has evidence based medicine become the third rail of health reform?Consider what President Obama said to ABC News's George Stephanopoulos:
"We know that we need insurance reform, that the health insurance companies are taking advantage of people," ..."We know that we have to have some form of cost containment because if we don't, then our budgets are going to blow up, and we know that small businesses are going to need help so that they can provide health insurance to their families. Those are the core, some of the core elements to this bill."
The President's words seem far removed from the contentious specifics of the Senate bill that the House refuses to pass unchanged. Evidence based medicine isn't mentioned let alone any specifics on "cost containment." The Cadillac tax contained in the Senate bill is illustrative of the challenges ahead.
In the Senate bill, the highly unpopular excise tax is not only designed to be a funding mechanism or means to contain costs. The hope has been that the tax would provide the incentive to practice evidence based medicine in order to squeeze savings out of a health care system where overtreatment is as much of a problem as lack of access to care or affordability. I have written about the relationship between the excise tax and overconsumption here.
The way forward for health care reform in general and evidence based medicine in particular is unclear for now and current efforts to find a new equilibrium point tend to focus on alleged errors of execution and how things would have been different if Obama had been more forceful or more conciliatory or if the Democratic candidate in Massachusetts had run a more effective campaign.
But I suspect the problem is more basic.
The majority of players in today's admittedly imperfect system are comfortable enough to be extremely wary of changes that promise to make things better in the long run, but could lead to inconvenience or worse first.
The changes for the better aren't guaranteed. The immediate adjustments are a certainty. Most people are simply unwilling to make that trade off.
Providing insurance for those who now lack coverage will require those of us who already have protection to pay more - whether the mechanism is higher premiums or higher taxes. People with insurance don't want to pay more. Understandably, they'd prefer to pay less. But that can't be done unless their costs are subsidized (which means someone else would pay more) or we are willing to change the system to make it much more efficient, a process resisted by patients and providers alike.
The adjustments that a more efficient evidence-based medicine would require are signaled by controversy around the issue of deciding the best age for otherwise healthy women to start getting annual mammograms.
There's data suggesting that raising it from 40 to 50 makes sense from a public policy perspective. On the other hand, some women in their 40s would be put at risk along with the income of the mammogram providers. Both of these groups strongly and understandably resisted.
But if we don't adopt evidence-based medicine, it is hard to see how we can make our system with the amply-documented massive overconsumption that now occurs more efficient. Proposals to nibble at the edges by reforming malpractice laws, restricting insurance companies or adopting electronic medical records are only marginally helpful in an environment where the normal treatment for any diagnosis escalates annually without necessarily improving health status.
Patients don't want experts/bureaucrats intruding in the relationship they have with physicians they trust. But unless and until this happens, it will be impossible to bring costs under control.
Theater is inevitable in our political debates, and the life-or-death decisions medicine addresses bring a big dose of drama that ultimately provides more excitement than illumination. We search for villains (evil insurance executives who earn millions) and heroes - like the physicians of Lake Woebegone, who deliver above average, even heroic, care.
In the end, we'll get more or less what we pay for. If we're determined to keep consuming more, we'll have to pay for it. If we're willing to embrace a system where some patients get less care some of the time, we can constrain costs. Until we confront that simple decision - and acknowledge that the latter choice will involve a complex and uncomfortable transition, progress will continue to be extremely difficult.
It isn't clear how to move in that direction and get the public to confront the difficult reality. Whatever their faults, politicians of all persuasions are not as masochistic as campaigns sometimes make them seem. That's why those who've fought so hard for the package that now hangs in balance are unlikely to voluntarily restart this debate anytime soon if the current effort fails.
