Regardless of the final direction health care reform legislation will go, comparative effectiveness research (CER) will be a part of it. While many see CER as a vital piece of the puzzle, some in the health care industry are on the fence about its actual value in improving health care as a whole. A New England Journal of Medicine piece I read recently, by Alvin I. Mushlin, M.D., and Hassan Ghomrawi, Ph.D., M.P.H., “Health Care Reform and the Need for Comparative Effectiveness Research” gave four straightforward reasons for how/why CER is both valuable and necessary in our existing system:

1. Findings from CER will provide a buffer against “blind” cost containment.
2. CER can identify preferred therapies, promoting changes in care and outcomes by identifying and validating such treatments. Such research suggests ways for new financial incentives to be applied both safely and effectively.
3. CER should enable innovation in medicine, by creating ‘disincentives’ for the development of “me too” drugs and devices, and by raising expectations and demands for clear evidence of superiority.
4. CER serves as what the authors call the “first line of defense against blind cost containment,” and can serve as a stimulus for the academic medical and public health communities, thus resulting in greater demand and more opportunities for physicians-scientists to get in on the research.

Let’s wait to see how CER fares in the final health reform bill—and if either side stifles the progress in science and service delivery that CER can bring about and that the health care system as a whole desperately needs.

If your organization is looking at increasing its private pay services, a new study, “Money or Mental Health: The Cost of Alleviating Psychological Distress With Monetary Compensation Versus Psychological Therapy” published in Economics Policy and Law and summarized in Science Daily’s "Psychological Therapy 32 Times More Cost Effective at Increasing Happiness Than Money" provides some powerful ammunition. The study found that four months of therapy increased "happiness" (as defined by the researchers Christopher J. Boyce and Alex M. Wood at the universities of Warwick and Manchester) as much as a $40,000 raise. The researchers concluded that "The research therefore demonstrates that psychological therapy could be 32 times more cost effective at making you happy than simply obtaining more money."

Despite the happy news for psychotherapy practices and the many vagaries of calculating well-being and happiness, the study speaks to the struggle of government policymakers in determining the 'relative value' of funding health services. "The researchers further draw on two striking pieces of independent evidence to illustrate their point—over the last 50 years developed countries have not seen any increases to national happiness in spite of huge economic gains. Mental health on the other hand appears to be deteriorating worldwide. The researchers argue that resources should be directed towards the things that have the best chance of improving the health and happiness of our nations—investment in mental health care by increasing the access and availability of psychological therapy could be a more effective way of improving national well-being than the pursuit of income growth."

These cost-benefit analyses, in health care analyzed through the lens of comparative effectiveness, will become more frequent as we have more data available through inoperable EMRs and there is greater pressure to reduce health care costs.

August 28, 2009

There is a thought-provoking article that came out in the August 19 edition of the Schizophrenia Bulletin, “Implementing Evidence-Based Practices for People With Schizophrenia,” by Robert E. Drake; Gary R. Bond; and Susan M. Essock. The article is a great summary of the current sad state of the treatment of serious mental illness at the consumer level. Despite significant research on what works, essentially people with serious mental illness are not getting the treatments they need. While the article is a great state-of-the-nation piece, based on our team's work in the public mental health system I think the recommendations need to be expanded.

Over the last decade, a number of systematic efforts to identify evidence-based interventions for individuals with serious mental illnesses have been made. However, although the interventions have been identified, numerous surveys have shown that consumers are not receiving these interventions. The report states:

Epidemiologic data from the National Comorbidity Study in the early 1990s showed that 60% of persons with serious mental illnesses received no treatment in the past year, 25% received clearly inadequate treatment, and only 15% received minimally adequate (far short of evidence-based) treatment.

The 2005 National Survey on Drug Use and Health found that only 8.5% of adults who reported both serious psychological distress and a substance use disorder received any treatment for both problems in the past year.

In their article, the authors recommend solutions that fall in the domains of information technology, state policy interventions, and federal policy interventions. But, I think these recommended solutions will have a limited effect if there are no changes to fundamentals in system design and financing, needed to assure that consumers with mental illnesses can get the services they need. I know the naysayers will contend that there is not enough money in the system to pay for these changes. I would counter that these are not behavioral health system issues. Rather they are health care issues—and these changes would be budget-neutral if we factor in the costs of emergency room visits and hospital readmissions alone.

To view my proposed solutions, check out: http://www.openminds.com/circlehome/circle/content_schizoebpstudy.htm