Health Affairs CER Briefing Highlights Key Issues

Just one week after the appointment of the board of governors for the new comparative effectiveness research (CER) body, the Patient-Centered Outcomes Research Institute (PCORI), health care thought leaders gathered at a briefing in Washington, DC to discuss the challenges and opportunities of integrating comparative effectiveness research standards into health care delivery. The briefing, hosted by Health Affairs and sponsored by the National Pharmaceutical Council, WellPoint Foundation, and the Association of American Medical Colleges, focused on the CER-themed articles published in the October 2010 issue of the health policy journal.   

“We’re off to a good start, but the future of CER is still fragile,” said Gail Wilensky, senior fellow for Project Hope and issue advisor for the October Health Affairs issue. She noted that despite CER’s role in the health care law, the highly charged political discourse in the upcoming November elections and the uncertainty of public acceptance of CER principles will determine whether it can have a meaningful impact in the national health care strategy to improve quality and value. With respect to CER, Wilensky continued, “Early wins will be very important.

NPC President Dan Leonard echoed the critical nature of the near term for CER.  In his opening remarks, Leonard pointed out now that the broader PCORI board is in place, all eyes will be on the development of the methodology committee, given its potential impact on how research is evaluated and integrated into treatment decisions and application.

New research illuminated some of the ingredients for success in securing public support for CER.  Survey work led by Eric Patashnik, professor of politics and public policy and associate dean of the Frank Batten School of Leadership and Public Policy at the University of Virginia, and Alan Gerber, professor of political science and director at the Center for the Study of American Politics at Yale University, revealed that the public is largely supportive of using CER to improve patient care and patient education, but that application of research to steer patient access to treatments is met with opposition.  According to Gerber, the most favorable “pro” message around CER is that the physician community wants CER and that public acceptance will hinge on continued engagement and “buy-in” from professional groups.

CER is a centerpiece of the national health care strategy in improving quality and achieving value.  With the first $1.1 billion to support CER, allocated by the American Reinvestment and Recovery Act (ARRA) signed into law last year, Joshua Benner, director of the Engelberg Center for Health Care Reform at the Brookings Institution, examined how those funds are being used.  At the briefing, Benner said, “We’re off to a good start.”  Of the $1.1 billion invested through ARRA, the majority has been spent on building CER infrastructure, supporting evidence development and synthesis standards, and meeting the goals of the allocated funding.   

Other panelists discussed approaches to optimizing the integration of CER principles into the health care system.  Lynn Etheredge,consultant for the Rapid Learning Project at George Washington University, discussed the imperative of transforming our system into a “rapid learning system” which would tap into existing and new databases and HIT systems to provide real time insights into interventions. Joel Kupersmith, chief research and development officer and director of the Quality Enhancement Research Initiative at the U.S. Department of Veterans Affairs (VA), pointed to the VA’s data driven research approach as a model for improving care.  He highlighted the VA’s diabetes program as an example of how their large database has been able to improve quality of care and refine their formulary.

While there is good consensus that evidence needs to be applied to health care decision making, the question of what kind of evidence makes the grade is another matter.  A second panel grappled with the challenges of identifying appropriate methods for conducting research, gathering data, and applying it to patient populations. Lou Garrison, professor and associate director of the pharmaceutical outcomes research and policy program at the University of Washington, urged leaders not to allow rigorous scientific methods to become a rigid evidentiary standard that precludes the use of a variety of approaches to gathering evidence. Nancy Dreyer,chief scientific officer for Outcome, discussed the value of observational studies:  “Quality research matters, and that’s what’s going to drive informed decisions about comparative effectiveness.”  Albert Wu, professor for health policy and management in the Bloomberg School of Public Research at Johns Hopkins University, underscored the importance of assessing what matters to the patients, including quality of life in evaluating treatment approaches.  Wu noted that, “Doctors collect a great amount of quality of life information, but it’s not systematically recorded.”

A key concern within the discussion on CER is whether it can help improve quality and value, yet still leave room for individualized care.  Robert Epstein,chief medical officer and president, Medco Research Institute, suggested that the right kind of research can actually amplify learnings around different populations, as has happened in the area of high cholesterol and heart disease.  He said, “Big banks of research will help in uncovering who benefits most from a given intervention.” Tony Coelho, chairman for the Partnership to Improve Patient Care, underscored the imperative of executing CER with individual patient needs in mind.  “You can’t just slap the words ‘patient centered’ on the process and have it be patient centered.  It’s harder than that, but we owe it to patients to be truly focused on what patients need.”    

Steven Pearson, president of the Institute for Clinical and Economic Review (ICER) at Harvard Medical School, stated that by law, CER cannot be used to set Medicare reimbursement rates, but the research findings should be taken into consideration. Pearson suggested that a system that bases payments on the superiority, comparability or inferiority of a new treatment to currently available treatments would help drive users of health care toward high-value care.

Susan Dentzer, editor-in-chief of Health Affairs, noted that the opportunities to improve health care have never been greater, but that unique challenges must be met in order to translate CER into something that is positive for patients. 

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