Perspective
Giving Teeth to Comparative-Effectiveness Research — The Oregon Experience
N Engl J Med 2010; 362:e18February 18, 2010
- Article
Experts believe that comparative-effectiveness research (CER) can substantially reduce future health care spending and improve the quality of care.1,2 Their analyses indicate that CER can control costs if its results are used to inform coverage, payment, and cost-sharing policies that provide incentives for appropriate and cost-effective care.1,2 But the proposed approach to CER in the United States would constrain these uses of the research, to avoid any implication that health care will be rationed. Though the word elicits fear and opposition, “rationing” is simply the equitable, or rational, distribution of resources; it involves delivering health care services according to clinical need and effectiveness, rather than wealth or geographic location.
True, rationing involves setting limits, and some Americans believe that when it comes to health, the resources available to doctors and patients should be unlimited. This position is facilitated by our insurance model, which insulates patients from the cost of care and rewards physicians for doing and spending more, even when the benefit is marginal or unproven. But there is ample evidence that in many communities, we overconsume health care, with adverse consequences for our economic and physical well-being.3 CER can help in shaping a menu of tests and treatments that optimize health while minimizing waste. But first we must get over our fear of the “R” word.
Several common assumptions make health care rationing anathema to the U.S. public. First, it is usually assumed that coverage decisions will be made by government officials or insurance executives, figures whom many Americans distrust. Second, some may assume that the decision-making process will be rote and mathematical, devoid of humanism and values. The reaction to recent recommendations regarding breast-cancer screening illustrated how even carefully deliberated, evidence-based decisions may be received if they do not appear to consider public values and priorities.4 Third, as evidenced by public conjecturing about “death panels,” some fear that boards that are charged with making coverage decisions will have excessive power and limited accountability and will undervalue the lives of the elderly and disabled. Finally, there is concern that rationing health benefits will impose a one-size-fits-all approach that restricts physicians' ability to deliver individualized care that is appropriate, even if not supported by population-based evidence.
In 1989, the state of Oregon set out to develop an approach to evidence-based coverage policy that would address these concerns. The state was designing the Oregon Health Plan (OHP), in which Medicaid-funded health care is administered mainly by private health plans. The principle behind the OHP was simple: when funds are limited, the state should deliver fewer services to more people rather than more services to fewer people. When costs rise or revenues are diminished, cuts should be made to lower-priority services, not to the number of people covered.
To prioritize services, Oregon created the Health Services Commission (HSC), a volunteer group of seven health professionals and four consumer representatives. The HSC was charged with setting coverage priorities, informed by public values elicited through surveys, focus groups, and town hall meetings. Public priorities and values included preventive care, mental health parity, cost-effectiveness, and personal responsibility, among others. Coupling these priorities with scientific evidence and expert opinion about treatment effectiveness, the HSC developed a prioritized list of approximately 700 condition–treatment pairs, rank-ordered according to importance. Actuarial calculations of the cost of services for patients in the target population are made every 2 years in developing the Medicaid program's proposed budget. The state legislature then draws a line on the list, and services above the line constitute the benefits package. Participating health plans must cover all services above the line, with some flexibility afforded when more than one treatment option is available. They can also cover services below the line, but in practice most health plans do so infrequently.
Oregon began using the prioritized list in 1994. As health care costs rose, the state used the list to reduce the number of covered services. In the late 1990s, however, the federal Health Care Financing Administration began denying Oregon's requests to move the line upward, and the number of people who were covered steadily declined. Critics have subsequently dismissed the Oregon approach as a failed policy. But the prioritized list remains in place today. Over the past 15 years, it has defined health benefits for more than 1.5 million people, many of whom would otherwise have been uninsured.
In 2007, the prioritized list was adopted as the basis for an essential benefits package in bipartisan legislation mandating that the state develop a universal-coverage plan for all Oregonians. In the proposed benefits package, the list is broken into tiers, with higher cost sharing for lower-priority services (see table
Structure of the Essential Benefits Package Based on Oregon's Prioritized List of Health Care Services.).5 The package includes first-dollar coverage for “value-based services” — low-cost, evidence-based services whose utilization is encouraged to prevent downstream costs and adverse outcomes. The proposal also includes incentives to encourage healthy behaviors, chronic illness management, and use of ambulatory care clinics, rather than emergency departments, for nonemergency care. If approved, this package will serve as a minimum set of covered benefits, beginning with public programs and health plans participating in a state insurance exchange.Setting priorities within health care is an imperfect process, and the Oregon approach has its limitations and its detractors. Nevertheless, it has stood the test of time. Several features are key to its acceptability. First, coverage decisions are made by doctors and patient advocates, not by government officials or insurance agents. Second, the process explicitly incorporates not only quantitative data on comparative effectiveness but also qualitative information on public values and priorities. Third, the HSC makes decisions for the covered population and does not exercise judgment in individual cases. HSC members include advocates for the elderly and disabled to protect against unintended discrimination. Fourth, the HSC is held accountable by having all meetings open to the public and by having the list reviewed biennially by the Oregon legislature. Fifth, Oregon is a state of fewer than 4 million people, and the HSC can accordingly be more accessible than a centralized agency and more responsive to the specific concerns of Oregon's patients, providers, and other stakeholders. Finally, although the HSC defines covered services and issues guidelines for some of them, it avoids being overly prescriptive and allows clinical judgment to guide individual care. When evidence is lacking or equivocal, the HSC engages Oregon physicians to provide expert opinions.
CER holds the potential for improving the quality and controlling the costs of health care but only if its results influence health care delivery. As health care reform proceeds, policymakers should consider empowering local, state, and regional benefits boards to use CER findings in shaping coverage policies. The work of such boards can be publicly accepted if it is conducted in a transparent, accountable, nondiscriminatory, responsive, and flexible way.
The opinions expressed in this article are those of the authors and not necessarily those of the Department of Veterans Affairs, the Oregon Health and Science University, or the state of Oregon.
Financial and other disclosures provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp0912938) was published on February 3, 2010, at NEJM.org.
Source Information
From the Section of General Internal Medicine, Portland VA Medical Center, and the Division of General Internal Medicine and Geriatrics (S.S.) and the Department of Family Medicine (A.K.S.), Oregon Health and Science University — both in Portland; and the Oregon Health Services Commission, Salem (S.S., D.D.C., A.K.S.).
- References
References
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Schoen C, Guterman S, Shih A, et al. Bending the curve: options for achieving savings and improving value in U.S. health spending. New York: The Commonwealth Fund, 2007. (Accessed January 26, 2010, at http://www.commonwealthfund.org/usr_doc/Schoen_bendingthecurve_1080.pdf.)
2
Analysis of comparative effectiveness. Santa Monica, CA: RAND Corporation, 2009. (Accessed January 26, 2010, at http://www.randcompare.org/analysis-of-options/analysis-of-comparative-effectiveness.)
3
Fisher ES ,Wennberg DE ,Stukel TA ,Gottlieb DJ ,Lucas FL ,Pinder EL . The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med 2003;138:288-298
Web of Science | Medline4
Truog RD . Screening mammography and the “R” word. N Engl J Med 2009;361:2501-2503
Full Text | Web of Science | Medline5
The essential benefit package: recommendations of the Oregon Health Fund Board's Benefits Committee. Salem, OR: Department of Human Services, 2009. (Accessed January 26, 2010, at http://www.oregon.gov/OHPPR/HFB/docs/BenefitCommitteeFinal.pdf.)
- Citing Articles (3)
Citing Articles
1
Nicholas F. Marko, Robert J. Weil. (2012) An Introduction to Comparative Effectiveness Research. Neurosurgery 70:2, 425-434
CrossRef2
2011. Can Research Guide Us to Improved Care at Lower Costs?. , 131-146.
CrossRef3
Hans-Jürgen Möller. (2011) How close is evidence to truth in evidence-based treatment of mental disorders?. European Archives of Psychiatry and Clinical Neuroscience
CrossRef
