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8/14/2019 Health Care Cost Monitor Act 1 The Hastings Center
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Health Care Reform: The Beginning of
the End, or the End of the Beginning?
Health Care Cost Monitor My, b
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aniel Calahand, Health Care Cost Monitor
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Contents
Comparative Effectiveness
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Politics
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Comparative Eectiveness: One Size Doesn't Fit All Peter Ubel, M.D. 1
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Comparative Effectiveness:
One Size Doesn't Fit All
eter el, ..
JULY 1, 2009 Does comparative eectiveness research orce one size ts all decision-
making? Not necessarily. With the right data, comparative eectiveness research can
improve medical care by splitting patients into relevant groups, rather than lumping them
all together.
COMPARATIVE EFFECTIVENESS
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Comparative Eectiveness: One Size Doesn't Fit All Peter Ubel, M.D. 2
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Peter A. Ubel M.D. is director o the Center or Behavioral and
Decision Sciences at the University o Michigan. He is author o
P L: Wy (MIT
Press, 2000) and Mk Md: Wy N-
Odd Ed Wy M (Har-
vard Business Press, 2009). His blog is www.PeterUbel.com .
paubel@umich.edu; 734-615-8591.
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How Comparative Eectiveness Research Can Save Money Susan Bartlett Foote 3
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How Comparative Effectiveness
Research Can Save Money
usan Bartlett Foote
JULY 7, 2009 The prospect o using comparative eectiveness inormation, especially in
relation to costs, causes concern in the eyes o those who would lose prots. In reality however,
an embrace o more research may reduce waste and unnecessary care.
COMPARATIVE EFFECTIVENESS
http://blogs.consumerreports.org/health/2009/03/comparative-effectiveness-better-care-lower-costs.htmlhttp://www.newamerica.net/blog/new-health-dialogue/2009/quality-comparative-effectiveness-whats-debate-11624http://jhppl.dukejournals.org/cgi/content/abstract/27/5/707http://jhppl.dukejournals.org/cgi/content/abstract/27/5/707http://www.newamerica.net/blog/new-health-dialogue/2009/quality-comparative-effectiveness-whats-debate-11624http://blogs.consumerreports.org/health/2009/03/comparative-effectiveness-better-care-lower-costs.html -
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How Comparative Eectiveness Research Can Save Money Susan Bartlett Foote 4
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Susan Bartlett Foote, J.D., is a proessor in the Division o
Health Policy and Management at the University o Minne-
sota. Her research ocuses on the inuences o public policies
o health care services, with an emphasis on innovation in
medical technology. She is the author o Managing the Medical
Arms Race: Innovation and Public Policy in the Medical Device
Industry. She served on the CMS Medicare Coverage Advisory
Committee rom 2004 to 2006. oote003@umn.edu; 651-336-7995.
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Comparative Eectiveness Research and the Doctor-Patient Relationship Eric Cassell, M.D. 6
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Eric Cassell, M.D., is an internist who practiced medicine or
almost 40 years. He is an Emeritus Proessor at Weill Medical
o Cornell University and an Adjunct Proessor o Medicine o
McGill Universitys Faculty o Medicine. He is a Master o the
American College o Medicine and a member o the Institute o
Medicine. He has written extensively about doctoring, the care
o the dying, suering, and moral problems in medicine. eric@
ericcassell.com, 917 365 5639.
mailto:eric@ericcassell.commailto:eric@ericcassell.commailto:eric@ericcassell.commailto:eric@ericcassell.com -
8/14/2019 Health Care Cost Monitor Act 1 The Hastings Center
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Virtual Colonoscopy: A Window into the Challenges o Health Care Reorm Ruth Faden and Sean Tunis 9
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Virtual Colonoscopy: A Window into
the Challenges of Health Care Reform
Ruth Faen an d ean Tunis
AUGUST 6, 2009 Medicares controversial decision in 2009 not to cover virtual colonoscopy
underscores the tremendous challenges involved in interpreting medical research ndings.
Although they examined the same evidence, dierent review groups emphasized dierent
risks and other scientic inormation. Such choices are judgments, not acts, and this is true
o all such clinical policy decisions, no matter how evidence-based.
COMPARATIVE EFFECTIVENESS
http://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298http://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298http://www.bcbs.com/blueresources/tec/press/ct-colonography-virtual.htmlhttp://www.bcbs.com/blueresources/tec/press/ct-colonography-virtual.htmlhttp://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298http://www.newamerica.net/blog/new-health-dialogue/2009/medicare-evidence-based-decision-making-12298 -
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Virtual Colonoscopy: A Window into the Challenges o Health Care Reorm Ruth Faden and Sean Tunis 10
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Ruth Faden, PhD., M.P.H., directs the Johns Hopkins Berman
Institute o Bioethics. raden@jhsph.edu, 443-287-0413. Sean
Tunis, M.D., directs the Center or Medical Technology Policy,
a nonprot organization in Baltimore and is the ormer Chie
Medical Ocer or Medicare.Sean.tunis@netzero.net, 410-
963-8873.
mailto:rfaden@jhsph.edumailto:Sean.tunis@netzero.netmailto:Sean.tunis@netzero.netmailto:rfaden@jhsph.edu -
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Cancer and Comparative Eectiveness Research John Geyman, M.D. 11
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Effectiveness Research
ohn eman, ..
AUGUST 25, 2009 It is no longer unusual or chemotherapy to cost more than $100,000 a
year. Oncologists are oten reluctant to be the bad guy by denying patients the option o
a treatment. Comparative eectiveness research may help determine which treatments are
truly valuable, controlling costs and improving quality.
COMPARATIVE EFFECTIVENESS
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Cancer and Comparative Eectiveness Research John Geyman, M.D. 12
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John Geyman, M.D. is a amily physician and proessor emeri-
tus o amily medicine at University o Washington. He is the
author o several books, including G and
D N : Wy I Idy
Dy, d W M I. jgeyman@u.washington.
edu; 360-378-6264.
http://theoncologist.alphamedpress.org/cgi/content/full/11/2/90http://theoncologist.alphamedpress.org/cgi/content/full/11/2/90 -
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Competition and Health Care Costs Joseph White 13
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oseph hite
MAY 29, 2009 Advocates or competition in health care are rarely deterred by the evidence
that its measures have never worked. While there should still be room or virtuous
competition in health care reorm, we must realize and accept that, at present, competition in
the health care system takes largely unconstructive orms.
COMPETITION
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Competition and Health Care Costs Joseph White 14
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http://finance.senate.gov/Stuart%20Altman.pdfhttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdfhttp://www.ourfuture.org/healthcare/whitehttp://www.ourfuture.org/healthcare/whitehttp://finance.senate.gov/Stuart%20Altman.pdf -
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Competition and Health Care Costs Joseph White 15
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Joseph White is Chair o Political Science, Luxenberg Family
Proessor o Public Policy, and Director o the Center or Policy
Studies at Case Western Reserve University. His most recent
book is : Wy G S Sy
d Md Sv .joseph.white@
case.edu; 216-514-8337
mailto:joseph.white@case.edumailto:joseph.white@case.edumailto:joseph.white@case.edumailto:joseph.white@case.edu -
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Competition: The Public Plan's Fatal Flaw Daniel Callahan 16
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Competition: The Public
Plan's Fatal Flaw
aniel Callahan
JUNE 19, 2009 The greatest aw o the proposed public plan is its embrace o competition
as the central mechanism or cost control. History suggests that competition as a whole is
an ineective way to run a health care system. Real reorm lies in price controls and other
regulatory strategies.
COMPETITION
http://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=ushttp://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=ushttp://voices.washingtonpost.com/44/2009/06/08/senate_republicans_send_obama.htmlhttp://voices.washingtonpost.com/44/2009/06/08/senate_republicans_send_obama.htmlhttp://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=ushttp://74.125.47.132/search?q=cache:thuonCJVY4EJ:www.healthreform.gov/2009healthcareletterpres.pdf+Obama+and+public+choice+plan+and+health+reform.gov&cd=8&hl=en&ct=clnk&gl=us -
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Competition: The Public Plan's Fatal Flaw Daniel Callahan 17
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Daniel Callahan is editor o the M.
http://www.politico.com/news/stories/0609/23755.htmlhttp://www.newamerica.net/publications/policy/modest_proposal_competing_public_health_planhttp://www.newamerica.net/publications/policy/modest_proposal_competing_public_health_planhttp://www.politico.com/news/stories/0609/23755.html -
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Deusing the Health Care Time Bomb: Lessons rom the 1990s Alain Enthoven 18
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We need ve actions:
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2. Organize the market or competition at the consumer level.
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livery systems.
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Defusing the Health Care Time Bomb:
Lessons from the 1990s
Alain nthoen
AUGUST 18, 2009 While the concept o managed competition rom the 1990s ell out o
avor, the ather o managed competition describes ways that it can be updated to improve
consumer choice and create incentives or more ecient health care delivery. Health care
would be o high quality, but premiums would be aordable.
COMPETITION
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Deusing the Health Care Time Bomb: Lessons rom the 1990s Alain Enthoven 19
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4. Address other barriers to an ecient aordable health care.
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Alain Enthoven, Ph.D., is the Marriner S. Eccles Proessor o
Public and Private Management, emeritus, at Stanord Univer-
sity and a core aculty member at Stanords Center or Health
Policy and Center or Primary Care and Outcomes Research.
He is known as the ather o managed competition. He is a
member o the Institute o Medicine o the National Academy o
Sciences. enthoven@stanord.edu; 650-723-0641.
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Health Care Reorm: The Role o Hospitals and the Need or Equity Blair L. Sadler 20
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Health Care Reform: The Role of
Hospitals and the Need for Equity
Blair . aler
JULY 13, 2009 A hospital reimbursement system in which every procedure and test
generates a acilities ee and a doctor ee is in need o reorm that rewards quality instead o
quantity. But reorm also needs to level the playing eld so that saety net hospitals dont bear
a disproportionate nancial burden.
HOSPITALS
http://www.kaiserhealthnews.org/Stories/2009/July/08/hospital-woes.aspxhttp://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrailhttp://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrailhttp://www.kaiserhealthnews.org/Stories/2009/July/08/hospital-woes.aspx -
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Fixing Medicare Muriel Gillick, M.D. 22
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Fixing Medicare
uriel illic, ..
MAY 22, 2009 Eective Medicare reorm requires implementing a coordinated, integrated
approach to the management o chronic disease. While Medicare is ailing to cover a variety
o services that are critically important or older patients, it is simultaneously paying or an
enormous amount o care that is useless and in many cases even harmul.
MEDICARE
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Fixing Medicare Muriel Gillick, M.D. 23
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Muriel R. Gillick, MD, is a geriatrician and palliative care
physician at Harvard Vanguard Medical Associates in Bostonand a Proessor o Ambulatory Care and Prevention at Harvard
Medical School. Her most recent book is D :
P Y, E L, d O D -
. mgillick@partners.org; 617-509-9977.
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Cost Trends in Heart Disease, End Stage Renal Disease, Cancer, and Metabolic Syndrome Polo Black Golde 24
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Disease, Cancer, and Metabolic Syndrome
olo Blac ole
MAY 22, 2009 The Medicare Trust Fund is expected to be insolvent in eight years at the
current rate o spending, as a result o more enrollees living longer and in worse health. Four
leading medical conditions underline this trend.
MEDICARE
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Cost Trends in Heart Disease, End Stage Renal Disease, Cancer, and Metabolic Syndrome Polo Black Golde 25
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Polo Black Golde is a research assistant at The Hastings Center
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Lie-Extending Treatments or the Oldest Patients Sharon Kauman 26
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the Oldest Patients
haron auman
MAY 26, 2009 The routine use o innovative lie-prolonging treatments has led to an
increase in interventions perormed on people in their 80s and older. I we do not better dene
medical success and the best treatment plans in an aging society, we may nd that we are
wasting money at the end o lie.
MEDICARE
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Lie-Extending Treatments or the Oldest Patients Sharon Kauman 27
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Lie-Extending Treatments or the Oldest Patients Sharon Kauman 28
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Sharon R. Kauman, PhD, is proessor o medical anthropol-
ogy at the University o Caliornia, San Francisco. Her current
primary research ocus is on the impact o medical technique on
individuals in an aging society. Her most recent book is d
D: S Ed L;
sharon.kauman@ucs.edu; 415-476-3005.
mailto:sharon.kaufman@ucsf.edumailto:sharon.kaufman@ucsf.edu -
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Is Death Optional? Muriel Gillick, M.D. 30
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v. Lk, v b b x , y d d
x , K . I y , d
dd -
d y b v
b bd.
Wy d y -xd
,
v, , d b d d
v y? Uy, yk
v k d -v d-
d MS v .
y d d b
k dy: d d dd d b
b d y -
y b b.
Muriel R. Gillick, MD, is a geriatrician and palliative care
physician at Harvard Vanguard Medical Associates in Boston
and a Proessor o Ambulatory Care and Prevention at Harvard
Medical School. Her most recent book is D :
P Y, E L, d O D -
. mgillick@partners.org; 617-509-9977.
mailto:mgillick@partners.orgmailto:mgillick@partners.org -
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Death by Rationing? Not Here Susan Gilbert 31
S db v
d - vy: v
vb d d by .
D. L , d Lvy
Sd Uvy, x
The New York Times, E v vy
v k v v dk
d.
, by J G, d
Timess N Od b, v y
k. S D W Dy d v,
k , N.Y., v
dy y vd x v
d , d -
vy d. I dd
v -xd ; b .
S Dy Q, x, 87 y d d dy
d, ddd k 23 d
d b bd . S dd v d b
, dd d vv
, G .
d-k b b -
v d k ky d y
b d, ky b v -
, d d.
x k
dy , d xv
d d , dbd v
.
O dd d
xd 80 d 90, d-
kdy d dy.
I , vd M Gk d-
bd 70 d d v k d
b k v IU vy - -
v. d b
d d xd v vvd IU, -
b d b d d d b x-
y dbd.
O dd b d
d ky vy , d
: bd
xvy , Gk .
I Times , D. b M,
, y y v b d y
Iv v . y, I d b
, d y d
bk y b
. I d d, M y
-d
dy b v d
d.
y d v. I -
qy -d New York Times Jy 9, d -
Death by Rationing?
Not Here
usan ilert
JULY 9, 2009 A congregation o nuns in Rochester, N.Y., who live their last days with
excellent palliative care in a supportive and stimulating environment, oten choose not to
have lie-extending treatments. A geriatrician who cares or the nuns told The New York
Times that they have better deaths than any I have seen. There is reason to believe that their
care be replicated outside the convent.
MEDICARE
http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://newoldage.blogs.nytimes.com/http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3482&blogid=87870http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?category=Medicare&blogid=87870http://www.nytimes.com/interactive/2009/07/08/us/20090708_SISTERS/index.htmlhttp://www.nytimes.com/interactive/2009/07/08/us/20090708_SISTERS/index.htmlhttp://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?category=Medicare&blogid=87870http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3482&blogid=87870http://newoldage.blogs.nytimes.com/http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1http://www.nytimes.com/2009/07/09/health/09sisters.html?pagewanted=1 -
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Reducing Regional Variations in Spending Anthony Mareo 34
b $420 b. d kd b
dv v
d, vy b v- , y v .
D dy ,
vy-dd y vd.
dvy by
d by d d . O
, d k d v dy
k f bk. v, d,
My vd , xd
dy y d, d v k
y b d .
v d b d; y
y y -dv v. -
d qy d qy d y,
y y, d d. df
y .
Anthony Mareo is a ourth year medical student at Yale.An-
thony.Mareo@yale.edu.
http://healthaffairs.org/blog/2009/06/17/geography-and-the-keys-to-health-care-reform/mailto:Anthony.Marfeo@yale.edumailto:Anthony.Marfeo@yale.edumailto:Anthony.Marfeo@yale.edumailto:Anthony.Marfeo@yale.eduhttp://healthaffairs.org/blog/2009/06/17/geography-and-the-keys-to-health-care-reform/ -
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Cost Control in Europe: Ineciency is Unethical Richard B. Saltman 37
I bv E -
xd vy
Ud S. qk y d q
Oz E d Dv-
(OED) E y v -
d .
yy b d
bdy E y,
by yk
.
yd d , v,
b x-dd d dd
E y U.S. y,
qy E d x-
d . Lk y
E, -
, y dd dd
, qy d v-
y . x, d y dy y.
d y
G Md ,
Sd v y d
v dd N
d d W. I , d
k d
b d d
d -
y d .
Y ky q b d
d, d y d
dv d. , Sd
, d W E yk v
, d y d dv
d y .
I Sd, dvdy-d
y S y
d y 300 k ($40) y.
b y d x-
b Sd ( 9.1 -
GDP 2005) d U.K. (8.3 GDP
2005) dd q ,
.
Additional examples include:
I U.K., d v v; , -
v vv -
v d, d ( ,
y) y d .
I Sd, 70 d d by x-
by d bdy y
d v vd.
b dd d dd
d, y v v b x d
Cost Control in Europe:
Inefficiency is Unethical
Richar B. altman
JUNE 10, 2009 Many o the dierences between the U.S. and European countries in health
care spending are the result o stricter budgetary constraints and oversight. Can measures
like government regulation o insurance premiums and coverage be implemented here?
OTHER COUNTRIES
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Cost Control in Europe: Ineciency is Unethical Richard B. Saltman 38
dd x x y
.
I y E , dv -y y y y v.
v v b vd x-
dd y d vv v,
ky d xd (q -
k d U.S., Md).
I I, E-y -
y, d b d d d
dd v bk v, k
d d by d dvy 70 -
b. N d d b ddd
dq d (d by x) dy v-
b.
v dbk dv. y dfy k
d v, d, x-dd
y, y b
vy ( y , U.K.)
v d.
y d y y d
zd U.S. y dd, d y
y v E-
. (D E-
y E Obvy.)
, b , -
v f. Ny E v -
y d b xd v,
y b dy .
, v k dd
d y xd. y , , y
d (d E -
, y) d
v v. v
vy b d y -
k y f d -
v.
y
E.
1. Regulating private insurers
Germany: P by y
v k .
Switzerland: y b
k dy b v, d
d v v qd -d
d, d bd q.
2. Expanding Primary Care Services
U.K. and Finland: v vv , v y
y v.
U.K.: dy v y
; y d
k xv . S-
d d W, v, v
y d y .
Finland: G d
, k y k -
v.
Denmark: GP d x db
7,500 D k (b $1,400)
d 1,000 k (b $180) vd y.
3. Supporting Home Care Services and InormalCaregivers
Germany: Gv y ,
b v y b d vd -
.
Sweden, Denmark, and Norway: v v
b y d -
y y b.
Sweden: Pvd , dv
, d v d
d k .
Netherlands: bd k- , d by
, dy , v d, k v
, d v v v bd b b-
vd v .
y dd d -
v dd v
d xv . I , d-
b y y d
dd xv v, ,
dy, d xv v b.
b y d by
j d .
d y -
dby xv y U.S.
y bd d
d by d-d b ( d
) d v (K P) vd.
b E v
http://www.euro.who.int/document/e87303.pdfhttp://www.euro.who.int/document/e87303.pdf -
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Cost Control in Europe: Ineciency is Unethical Richard B. Saltman 39
v, y f v-
y: dy d
y v xd- y .
yk j dv
y E y
d dv y -
d vd.
v v
bk y dd E -
d. I v dy -
y d , yd , , d -
, y d y W E M
, b d y-
k x U.S.
M dy, v -v W y d-
d by M d/ 27
E E U Pdy
Sby Sy, d P
My 11 d 12. xd, E yk d-
d k y v d
f.
Sk d d M Dz
(d WO Of E) , -
, fy . Eqy,
d d by dd v-
d d d
d dd b v -
.
D k U.S., y
b dd d d
E x, y v
, Szd. vy
vvd d vy xd b , d y x
b y x.
, xdd dy,
d 7 10 GDP
k y d b b b
d v bd
y. M U.S., d 16
GDP , by dv
dd b xd-
, y v y xd v
.
I d vy d - d d E-y y -
b dq v b
dy -
z yk U. S.
Richard B. Saltman is Proessor o Health Policy and Manage-
ment at the Emory University School o Public Health. He is
coounder o the European Observatory on Health Systems and
Policies in Brussels and is currently head o the Atlanta hub He
has published 16 books and over 130 articles and book chapters
on a wide variety o health policy topics, particularly on the
European health care systems. He has twice won the European
Healthcare Management Associations annual prize or the
best publication in health policy and management in Europe.
RSALTMA@emory.edu; 404-727-8743.
mailto:RSALTMA@emory.edumailto:RSALTMA@emory.edu -
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Cost Control in Canada: Complaints o Underunding Theodore Marmor 40
v y b d d
Ud S 2009 d
v 1993-4. -
y db , x Wall Street
Journals y, ky . dy
Gy, d, , Ud K-
d, b-
vy d y .
S, k d y vd -
v v d-
b. d 10 v -
d d y v
y ddb, -, -y.
k / Sd y 1960,
x d.
d d Md d
y xdd : v
k 1957 1961 v dy d-
d . Lk, y y b-
1967 d 1971.
d Md b d y v d dd, b d -
d dd y d
d-1990 v v bd k
d xd y. dy,
Md -
y d y v
v, 2005 S d-
d v v Qb
v . I , v
d b v
by dd v.
d v
y y k U.S. My y
y vy kb d d -
d z. W dd
v x, d ( ). d
d bd v
; dv, , q d ; d
y dby (10 d
v U.S. 16 17 ) b.
b b d U.S
b d d d y
y y y. U.S. d
y d .
Iy, d k U.S. y
d d y b U.S. Md d
, y y
v d d dy d
y. d y
b y, U.S. Szd vd .
Udd b , d
y
d b.
d bd d x d
.
y d bv,
q by. G d v y d
k v y d. d -
Cost Control in Canada:
Complaints of Underfunding
Theoore armor
JUNE 12, 2009 For over three and a hal decades, Canada has provided health insurance
coverage to its entire population while delivering decent care. Canada continues to control
costs exceedingly better than the U.S. by sticking to a budget.
OTHER COUNTRIES
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Cost Control in Canada: Complaints o Underunding Theodore Marmor 41
d vy b ,
y v, y.
, I d , b - d d b -
d b bd. S d bv
vy d b b y v -
v , k, qzd v-
bd. v U.S. x -
y bj vy
bd d .
dd, U.S. k y
vd dv v k d d.
y y, y d bd x
v b v, -
by , x , -
- (ddb, -, -y), d
d d d.
b d: -
z v ( MO PPO d byd) d
xd. I b 1970, U.S.
d d y GNP
d (y 7 ). y y ,
U.S. d 50 d
d d, , v -
--k d.
v v bv b
y d q d. O x
d b d
.
My d b k
d y dd
ddv . I d
Md , y bkd. W b-
d d Md d y
v v y, bd d -
b v d d d .
W d, d E-
y d Nd , dd
v . d S zd
W E d
v d
U.S. ( d d
b v xd, q
v U.S. dd.)
M z b
Nd, y x -
y .W k v x, I d
yd by d b xd
x d v . d,
U.K., Sd, Nd, Gy x bd-
q b d d . I
d bd x , -
v d/ x b d. v
y.
N x d
d. W dv d d -
d . , I
k, v d b
U.S. 2009.
Theodore Marmor, PhD, is Proessor Emeritus o public policy
and management and o political science at Yale School o
Management. His books include P Md;
Theodore.marmor@yale.edu, 203-376-7739.
http://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3486&blogid=87870mailto:Theodore.marmor@yale.edumailto:Theodore.marmor@yale.eduhttp://www.thehastingscenter.org/HealthCareCostMonitor/Default.aspx?id=3486&blogid=87870 -
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How Nice is NICE? A Conversation with Anthony Culyer The Editors 42
N I Ex (NIE)
d vy -v
d v d d d dv. U
y, Ud Kd y y k
, b , d , -
z, b, d d, y NIE
y v . W kd y J.
y, PD, d Dv -
NIE, d y d dd -
.
What is the role o technology assessment in the U.K.health care system?
dy k, U.K. b -
d y. O d v
d v -
bd v b .
, d N Sv (NS), d x-; vd b -
v d NS.
y y y v
v db vd
y k. W vd f b d-
, db d v-
d-d dk, d d d vd
vb d.
k NIE dv vy y.
b y dd d.
dd 1950, dq d
b d y, -
dd d d k -
dd d d b
k.
How does NICE t into technology assessment?
by , NS
k d k dd q k
NIE y NS v d-
b . NIE z. I , -
v, j .
NIE y d y d
, by b, d bd d v
b bqy vd y xv d d
kd, d dy.
xz b NS vd vv, d, v
v, d y, dy y
.
-v NIE y
xd qy-dd y
d 20,000 30,000 (b
$26,000 $36,000) b dd.
d b qy (, x-
, v ) jdd by v
How Nice is NICE? A Conversation
with Anthony Culyer
The itors
JUNE 22, 2009 Britains National Institute or Clinical Excellence (NICE) assesses the
relative health benets o particular procedures. Creating incentives to invent new products
that are cost eective will lead to better health and more cost containment, argues Culyer,
chairman o NICEs Research and Development Committee.
OTHER COUNTRIES
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How Nice is NICE? A Conversation with Anthony Culyer The Editors 43
. v d x d
b dd.
What kind o authority does NICE have?
NIE b y. I guidance,
b d b d, d
k d d d dv. d
q, d d -
qy , d
, -d, d
y ky b v.
L d vd mustk y
y dd by NIE vb -
qd by y. I , NIE b
dyphysicians v d. d NIE d b, -
y , y x-
by dv d,
, d d b
d d vy.
What is the role o QALYs in decision-making?
NIE d v Qy-dj-
d L-Y (EQ -5D), y
b NIE dvy k -
b y b d d b
dd b bk d y -
v .
QLY , . I y d
-v .
QLY d b-
d, d
d dvdd by QLY d
d d , -v
y dd. -
--QLY d , d y
xd , d
b v d.
I y , v, QLY vb dq x. -
d v dvy y
QLY d
d NIE y -d jd
d.
--QLY b d bb
v d. I d jd,
d, y q d x
.
Is NICE a threat to physicians reedom to practice? Is it athreat to industry?
NIE d j : d.
x
dv d d b d
k.
b y b vd b -
.
W d ky NIE
k-k d d d
dy ky .
, d x b y
-bd d y y
d v. I
, d, v v d -v, b d
v v both b and
.
Are recent attacks on some NICE decisions evidence osome deep unrest?
d . W d d -
z v , NIE k
bd v, .
I vb b . I
vb v jd d
, v b d x
vy y , b. NIE d b
v d b v b
v vy .
y b b d
I b NIE d
y bd d-k d
y dy. , v, d
b b d
vb d y v dd
v. b b k b -
y d dd vb
.
Are any important reorms in the NICE program likely?
NIE d d
d kdy v
k d v . -
xd NIE k dv d.
b b k d
vd b, k, d, bd.
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How Nice is NICE? A Conversation with Anthony Culyer The Editors 44
y d NIE
y b y
vv - d , d
qy . NIE k
y -
d, b , d, -b -
v d, b qy
vd b.
b
NIE . Sd d-
d? W b d? O
d? W b dv
d d v -
vd by
k?
v x
kd d x d. W -
v x , v
dvd v k -
. I NIE k y ! NIE y
b y f.
v NIE
d b d b ddd
y d y
.
Anthony J. Culyer, PhD, is the Ontario Research Chair in
Health Policy & System Design at the University o Toronto
and proessor o economics at the University o York, England.Ajc17@york.ac.uk; 011-1904-433762.
mailto:Ajc17@york.ac.ukmailto:Ajc17@york.ac.uk -
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Comparative Eectiveness and Rationing: Lessons rom NICE Mark Heland and Louise Russell 45
vy d v 2009 d-
d $1.1 b v v -
d d d
d v.
y v v d
vby d . Wall Street Journal
d d v v
. G W dd -
v v d dy dv
v d . I
d y v d .
y ,
N I d
Ex (NIE), v v d
-v y dv N
Sv d b vdd -
v. : b q d
b NIE. I , y
d d b - d v v .
d 1947, N Sv (NS)
d vy vy 50 y b
NIE bd, y by bd -
v y d k . bd -
d, NS y zd d vy-
vybdy. I , d
NIE d y v d-
d, db y by v.
W NIE d y vb
NS vy d y. NIE
b b NS bd. O
d .
W NIE d 1999, dd d
dd q b
d . D. G L, b NIE d d
Dy Exv d O Of NS
Evd, dbd y: W -
vd d by ---
d d, vd x d
b dd, v
y . I dv y
ddz v
NS vd d y y d
W d d
y.
y d
dbd Ud S dy, d q v
y 10 y .
dy d dd v -
, y y v, y v dvd
, d b v , Dvd L-
d d y The New York Times.
Mv, d v d by
, D , d v
Md d Mdd y.
Comparative Effectiveness and
Rationing: Lessons from NICE
ar Helan an d ouise Russell
JUNE 22, 2009 American attempts at comparative eectiveness research have prompted
charges o rationing. However, a ree ow o inormation about benets, harms, and costs
through publicly unded comparative eectiveness research could improve health care in the
U.S. Examining how Britains NICE uses this research suggests potential benets.
OTHER COUNTRIES
http://online.wsj.com/article/SB123318915075926757.htmlhttp://online.wsj.com/article/SB123318915075926757.htmlhttp://www.washingtonpost.com/wp-dyn/content/article/2009/01/28/AR2009012802939.htmlhttp://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&scp=1&sq=David%20Leonhardt%20and%20rationing&st=csehttp://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&scp=1&sq=David%20Leonhardt%20and%20rationing&st=csehttp://www.washingtonpost.com/wp-dyn/content/article/2009/01/28/AR2009012802939.htmlhttp://online.wsj.com/article/SB123318915075926757.html -
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Comparative Eectiveness and Rationing: Lessons rom NICE Mark Heland and Louise Russell 46
y , b b d x b
d y v b d v y b ,
d v d v, v dd. v d NIE -
d vk -v.
y v d .
, y , NIE y y, NS
bd vd vy y.
Sd, NIE b b. ,
, y , d kd
k xy vd, , d d-
d d. Ov , d b y-
b , d d
x d qy d v d-
k.
y, x, y d v b -v, NIE vd -
dd y d d
. NIE
y d , b
d bd xy.
, NIE y d d
b ky b. y d
y v d v -
dd v
dy vb.
NIE d , xd NS
bd, bd v d d v
k y v vd
b y. , dd
-v y , kdd
d d q d ,
, NS y y -
d y
.
I U.S., xd bd ,
v v
y , b d by
dvd d y, d
d y d . N
y, , Db 2007 d O- d v v
d by .
d NIE, U.S. v v
d v-
d. , b k v dd d d d y,
k d d
by b d v.
d d dv, x, -
d d d D d-
d d
q b k b d
d . d d kd -
, d v d v, d
k d v b
d k d b
.
Sx, d Annals o Internal Medicine, y d ky dd
Py 2009 I Md : b
y y dy--
d . b y d
d b d
vy d k k d d. W
y NI-d
x. v, NI d -
dy.
I , U.S. k v v
y b . I b
dd b b,
d . W , by dd -
v v d v
U.S. by d d bz dd,
v b k b .
Mark Heland, M.D., is editor-in-chie o the journal Md
D Mk, a sta physician at the Portland V.A. Medi-
cal Center, and a proessor o medicine at Oregon Health & Sci-
ences University, where he directs the Oregon Evidence-based
Practice Center. heland@ohsu.edu, 503-494-4277. Louise Rus-
sell, PhD, is an economist and research proessor in the Insti-
tute or Health and a proessor in the Department o Economicsat Rutgers University. She is an associate editor o the journal.
lrussell@if.rutgers.edu, 732-932-6507.
http://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtmlhttp://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtmlhttp://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtmlhttp://www.cbo.gov/ftpdocs/88xx/doc8891/Frontmatter.1.2.shtml -
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NICER in the U.S.? Steven Pearson, M.D. 47
dy I d y y yy v y
NIE, I y dy v NIE
d d k -
U.K. dbd -
d dd d d
y y, b
d.
xd, d b -
d by NIE, v d
d, N Sv
-v d d d. S.
W y y, v, yb-
, d v k NIE d
v --- q
. I I
d , y b NIE U.K., b
v b b b d
v v
b b d Ud S.Ud: Why would anyone in their right mind wish to
deny such drugs to people with a lung condition in the rst place?
Madness. It was probably all to do with money like it is when peo-
ple with cancer are denied drugs to help prolong their lie. Seems
that there is always enough money to ensure that smacked up
drug addicts get their methadone though. To sum up: Put yoursel
in a situation requiring ree drugs and youve got it. Be unortu-
nate to suer through no ault o your own and youll have to ght
or your right to lie saving drugs. What a Country eh?
Yky: Well said, Utdlass, I cannot agree with you
more.
W d, I k, -
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NICER in the U.S.?
teen earson, ..
JUNE 26, 2009 Although NICE has been labeled un-American, the U.S. may end up with
an entity like it to oversee the comparative eectiveness research mandated by the stimulus
legislation. However, such a body in the U.S. would not in act be NICER, because it would
ail to take cost into account, make clinical recommendations, or do little more than dissem-
inate technical reports.
OTHER COUNTRIES
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NICER in the U.S.? Steven Pearson, M.D. 48
Ud S.
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NIE Ed v d y y
NIE U.S., b y,
d d, yb z :
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NICER in the U.S.? Steven Pearson, M.D. 49
v y v b db-
b d , k
y v y;d d d
E dd 10 y y zd
y d k d .
Steven Pearson, M.D., M.Sc. is ounder and president o the In-
stitute or Clinical and Economic Review (ICER), an academic
group at Massachusetts General Hospital in Boston that o-
cuses on health technology appraisal policy. He spent a year at
NICE as a Senior Visiting Fellow on an Atlantic Fellowship in
Public Policy, and then served as a special advisor at Medicare
and as a senior ellow at Americas Health Insurance Plans.
spearson@icer-review.org, 301-435-8717.
mailto:spearson@icer-review.orgmailto:spearson@icer-review.org -
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Doctor Choice Abroad Richard B. Saltman 51
I d, b y
d (d y). b
b d by y y d,y E (d by
y).
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k .
Specialist care
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U.K., Dk, Sd, d, Ny, S, d
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Richard B. Saltman is Proessor o Health Policy and Manage-
ment at the Emory University School o Public Health. He is
coounder o the European Observatory on Health Systems
and Policies in Brussels and is currently head o the Atlanta
hub He has published 16 books and over 130 articles and book
chapters on a wide variety o health policy topics, particularly
on the European health care systems. His new volume on Nordic
Health Care Systems, co-edited with Jon Magnussen o Norway
and Karsten Vrangbaek o Denmark, will be published later this
month by McGraw-Hill Education.RSALTMA@emory.edu;
404-727-8743.
mailto:RSALTMA@emory.edumailto:RSALTMA@emory.edu -
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Speaking Truth to Evasion Daniel Callahan 53
k k .
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vd. I d k y b d b jd. W bv
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Daniel Callahan is editor o the M.
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Ending the Cost Insanity: Some First Steps Henry J. Aaron 54
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Ending the Cost Insanity:
Some First Steps
Henr . Aaron
MAY 20, 2009 Fragmentation o payers, cost insulation, and an excess supply o services
without research into their eectiveness have made our current health care nancing system
as immune as possible to cost discipline. How can talk o controlling health care spending
move beyond just talk, and little else?
POLITICS
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Ending the Cost Insanity: Some First Steps Henry J. Aaron 55
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Ending the Cost Insanity: Some First Steps Henry J. Aaron 56
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v , d jy -
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y, k d vd v d .
Henry J. Aaron is the Bruce and Virginia MacLaury Senior
Fellow at The Brookings Institution. His areas o research
include the reorm o health care nancing and public health
care systems such as Medicare and Medicaid. This article was
adapted rom Aarons remarks or the twentieth anniversary o
Harvard Medical Schools Department o Health Care Policy.
HAARON@brookings.edu; 202-797-6128.
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Cost Control: Where Does it Stand? Daniel Callahan 57
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