Former Medicare Chief Says Comparative Effectiveness Research Is Not Rationing, Contrary to View of Obama Nominee Donald Berwick

By Matt Cover | June 3, 2010 | 8:31 PM EDT

Dr. Donald Berwick (Photo from Harvard University School of Public Health Web site)

( – Mark McClellan, the former head of the federal Centers for Medicare and Medicaid, along with several government and private researchers, said that comparative effectiveness research is not health care rationing. This view is contrary to that of Donald Berwick, who has been nominated by President Barack Obama to fill McClellan’s former position.
In a 2009 interview about comparative effectiveness research, Berwick said, “The decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open.”
On Thursday, speaking at a forum sponsored by the Brookings Institution, McClellan – who was director of the Centers for Medicare and Medicaid in 2004-2006 -- said the purpose of comparative effectiveness research (CER) was to help doctors avoid costly, unnecessary treatments, not to decide who does and who does not receive care.
When asked by about Berwick’s views on CER and rationing, McClellan said he disagreed with the idea that CER is a tool for rationing and stated that it would lead to better, cheaper health care.
“The whole intent is to help some very diverse populations get better treatments and avoid unnecessary costs,” McClellan said. “That’s something that we are clearly not doing a very good job of in our health care system. So I wouldn’t view that as being about rationing. I would view that as about improving care as well as avoiding unnecessary costs and improving value.”
“I don’t see how you achieve that goal without really taking on exactly the kinds of issues we’re trying to deal with [in comparative effectiveness research],” said McClellan.
Joel Kupersmith, head of research and development for the Veterans Health Administration, also disagreed with Berwick’s claim, saying that researchers must get clinical data into the hands of doctors so they can “see what’s good.”
“We have to get information on effectiveness, and that will include differences on resources required,” he said. “We need to see what’s good.”
Kupersmith, a cardiologist, said that CER was most beneficial to patients because doctors who know which treatments work best can provide their patients with the cheapest, least invasive care.

President Barack Obama waves goodbye as he boards Air Force One to leave the Quincy Regional Airport on Wednesday, April 28, 2010, in Quincy, Ill. (AP Photo/Adam Gerik)

“If you follow that [comparative effectiveness research] you can save money; but you will also save risk and all kinds of other things to the patient from doing this. You will save delays in surgery, so we have to start with effectiveness,” he explained.
Ruth Brannon, director of Research Sciences at the National Institute on Disability and Rehabilitation Research, said that CER was about “adding knowledge,” not rationing care.
“I think what this is about is adding knowledge where we don’t have sufficient knowledge to make decisions,” she said. “Where we have to guard against is having that become ideology -- and that’s what the debate is really about. We just need to be aware. But that doesn’t mean you don’t continue to seek better information on which to make decisions, which is the heart and soul of what CER is.”
Newell McElwee, executive director of Health Outcomes Research for pharmaceutical giant Merck & Co., said that CER would not lead to rationing but would help doctors make better decisions by giving them the best information.
“The R-word is kind of an incendiary word I think in this country but if you just sort of forget about the word for a second and think about what we’re really trying to do here, the premise is that if we have better information we’ll have better decisions,” he said. “There’s a lot of things that we do in this country for which we have absolutely no evidence or very poor evidence.”
“So when you think about it from that perspective, I think it really makes a lot of sense that we should go down this path.”
In the June 2009 interview in Biotechnology Healthcare, Obama nominee Donald Berwick was asked: "Critics of CER (comparative effectiveness research) have said that it will lead to rationing of health care."

He answered: "We can make a sensible social decision and say, 'Well, at this point, to have access to a particular additional benefit [new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.' We make those decisions all the time. The decision is not whether or not we will ration care--the decision is whether we will ration with our eyes open."

In the same interview, Berwick also said, “The social budget is limited -- we have a limited resource pool. It makes terribly good sense to at least know the price of an added benefit, and at some point we might say nationally, regionally, or locally that we wish we could afford it, but we can’t.”