Research as an "Honest Broker"

Ask people about the aim of comparative effectiveness research, and you’ll likely get a dozen different answers:  providing a valuable tool for physicians; enabling an inevitable power grab by the government to take decisions out of the hands of doctors; learning if we’re getting value for what we spend our health care dollars on; creating the rationale for rationing expensive care.  All of these viewpoints have been passionately argued already, and will be bandied about even more in the months ahead.  But a fascinating interview with President Obama adds one more to the list:  neutral arbiter between doctors and patients, enhancing and empowering both.

Section 5 of the New York Times interview focuses entirely on Obama’s thoughts about the unanswered questions of health care, particularly on why comparative effectiveness research in particular is a necessary part of the solution.  His explanation is plainspoken enough, sensitive to the false argument that any such research inherently disrupts the doctor-patient relationship:

[The research] is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one.

Common sense – hardly seems worth the fuss, let alone the endless comparisons to the Nazis that we’ve heard since the stimulus bill debate.  But here’s where it gets interesting.  Obama is not afraid to say that the doctor-patient relationship is not in any way an equal one:

I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.  And so, in that sense, there’s always going to be an asymmetry of information between patient and provider.

I’ve written about this before, but the anti-reform fear mongers tend to embrace the doctor-patient relationship as though it were both sacrosanct and infallible.  Yet the estimated $700 billion a year spent on unnecessary care or care that is not better than cheaper alternatives suggests that in reality, it’s all too human.  We hear from conservative health care advocates about individual responsibility and consumer choice – the notion, best exemplified in John McCain’s health care plan, that if you simply force patients to have more skin in the game and act like a consumer rather than a patient for whom costs are largely invisible because of insurance or public coverage, they’ll make better choices.  This has never made any sense to me – in part because, like Obama, I’m likely to give my doctor’s recommendation the benefit of the doubt.  She’s not a salesman who may know more about her company’s model, but isn’t likely to know much more about vacuum cleaners in general than I do.  She’s someone who went pre-med throughout college, spent 4 years getting a DO degree, went through at least three years of a supervised family medicine residency at a teaching hospital and has been in private practice every day for years.  I’m a guy who knows a fair amount of policy and politics, but jack diddly about medicine.  It’s going to take a lot for me to overrule her – even when she’s wrong.  I just don’t know enough, nor am I likely to.

In practice, as Duncan Cross succinctly puts it, the consumer-driven proposed reforms “aren’t about patient empowerment so much as forcing sick people to bear the burden of their contingent circumstances.”

Yet from his answer, comparative effectiveness research is patient empowerment in the Obama vision.  It’s not about government arbitrarily deciding – it’s about giving doctor and patient better-than-WebMD information on treatments.  Research through the NIH or other agency becomes the “honest broker” to begin to equalize the relationship between doctor and patient, especially if they both have access to the same information.  Doctors are the medical authority, but even they can’t argue with the scientific method.  And moreover, we know that some patients would welcome having good information.  Heck, some patients now act on bad information – as in “Ask your doctor if Flomax is right for you” based on a commercial bereft of any evidence whatsoever.  We can only do better with more education.

It’s a nice thought, even though there’s no clear idea of how Obama would implement such a thing.  Nevertheless, it has the potential to transform our health care system far better than any refundable tax credit would.

(Photo credit: The Official White House Photostream on Flickr.)