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How Will Proposed Health Care Overhaul Affect Patients?

November 26, 2009 at 12:00 AM EDT
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Ray Suarez sits down with medical experts to talk about possible changes to the U.S. health care system as Congress prepares to vote on a major overhaul.
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JUDY WOODRUFF: Now, as the nation considers reforming health care, a discussion on changing the way medical decisions are made.

Ray Suarez is in charge.

RAY SUAREZ: Since the health care reform debate began months ago, one key goal repeatedly discussed is lowering costs and improving quality by practicing what’s called evidence-based medicine. That refers to using scientific data in studies to inform decisions about the most effective treatments.

President Obama himself made the case for it during a prime-time news conference earlier this year.

U.S. PRESIDENT BARACK OBAMA: Why would we want to pay for things that don’t work? That aren’t making us healthier?

And here’s what I’m confident about. If doctors and patients have the best information about what works and what doesn’t, then they’re going to want to pay for what works.

If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?

But the system right now doesn’t incentivize that. Those are the changes that are going to be needed — that we’re going to need to make inside the system.

RAY SUAREZ: But, in light of the recent uproar over mammograms and cancer screening, there has been questions about whether evidence-based medicine is the right approach in health reform.

We get two views from people who have studied it. Dr. Donald Berwick is president of the Institute for Healthcare Improvement. Dr. Jerome Groopman is professor of medicine at Harvard Medical School and chief of experimental medicine at Beth Israel Deaconess Medical Center.

Dr. Berwick, let me start with you. Give us your best thumbnail definition of evidence-based medicine.

DR. DONALD BERWICK, president, Institute for Healthcare Improvement: It’s basing decisions we make as doctors and nurses and other practitioners on the experiments and trials that we can do to assess the effectiveness of operations or pills or tests. It’s — it’s flying with knowledge, instead of flying blind.

RAY SUAREZ: So, taking perhaps just a second before moving ahead with a course of treatment and assessing what we know about best results?

DR. DONALD BERWICK: Yes. It’s making up your mind about what you think works and what doesn’t based on evidence, instead of habit or just beliefs.

Making a considered judgment

RAY SUAREZ: Well, that was my next question for Dr. Groopman.

Evidence-based, as opposed to what? What are the other tools that a diagnostician makes that -- makes use of?

DR. JEROME GROOPMAN, professor of medicine, Harvard Medical School: Well, I think every good doctor should look at evidence. And putting medicine on a firm scientific footing is precisely what we want to do.

The problem is that the evidence we have comes from statistics, from clinical studies. And they may not apply to the particular patient whom you're caring for. So, then you have to make a considered judgment. You look at the evidence but then you may also draw on prior experience with other patients similar to this one, because not everyone fits into the -- the category where the data come from.

There's also important attention to the preferences of people, what a patient wants, the quality of life. Do they want to take the risks of that blue pill or red pill versus no treatment? And, often, we try to encourage them, but we should never coerce them.

And most importantly, I think, is that evidence changes. There is no -- often, it's not absolute. We get new information from new studies, but, also, what we call best practices comes from a group of experts sitting together and making judgments.

I have -- you know, on those committees, there are often credible experts who disagree with the data, just like we're seeing in the mammogram debate. And it's not a matter of being ignorant of science. It's a matter of judging the quality of the evidence and how broadly it applies.

So, I think everyone agrees evidence is extremely important. But we need to be flexible. And, most importantly, we should never mandate that every patient be treated according to one protocol.

RAY SUAREZ: Dr. Berwick, what about some of those points? And let's begin where Dr. Groopman began, that not every patient presents in a way that fits neatly into your use of evidence data to -- to figure out a course of treatment.

DR. DONALD BERWICK: Well, that's essentially right. A good -- a good doctor, doing his or her best to take care of a patient, is combining the kind of evidence we're talking about with other factors that Dr. Groopman is mentioning, like values, uncertainties, specific things you can know about a patient.

But I would still claim evidence is always better than not evidence. Having -- having the scientific knowledge provides better input to decisions like that. And, by the way, we have a lot of evidence that very clear-cut cases, where we know what works and what doesn't, are not -- that information is not honored in decision-making.

There's a kind of chaos out there in the health care system, where a lot of things that patients should get, they don't, and, a lot of things that they shouldn't get, they do. So, there are a lot of such clear-cut cases. And, in those cases, I think we should be raising the bar a bit on how strictly we want to adhere to what science is telling us.

RAY SUAREZ: Well, what about the point that Dr. Groopman made that evidence changes, that what we know or think we know for sure one year may not be the case further down the road?

Need for more research

DR. DONALD BERWICK: That's a prescription for how you should engage in evidence-based medicine, which is continually to monitor and update what we know. We're way underinvested in the kind of research that Dr. Groopman's comment would imply.

We need to invest much more as a nation in the continuous study and updating of knowledge as things go along. To -- to lock ourselves in, in concrete at any particular point in time is a mistake, because, as Dr. Groopman says, things will change. But we will only know they change if we keep doing the research.

RAY SUAREZ: Dr. Berwick, is there a risk that, when a patient comes in through the front door with a mix of the known and the unknown, that we will, in effect, put them in a slot, in a category that -- that fits the evidence that we have at hand, rather than forcing us to go places where perhaps our experience isn't as much of a guide?

DR. DONALD BERWICK: Absolutely there's a risk. And that's why it's wise not to put handcuffs on physicians or nurses and others when they make these decisions. We need to honor judgment and welcome judgment.

But we also need to honor evidence and science. And, in the end, we want to inform the encounter with the best knowledge we possibly can, and then leave a wise patient and a wise doctor to make the best choice for the patient.

RAY SUAREZ: Dr. Groopman, does the available evidence tell us enough when trying to figure out where to go next with a patient in the case of women and minorities, who often have not had the best track record in -- in clinical trials, because they are undersampled or -- or underinvestigated?

DR. JEROME GROOPMAN: Absolutely. This is one of the great gaps in evidence.

And I think, as Dr. Berwick, whom I know as Don, just said, it's very important to invest in getting this kind of information. Different ethnic groups, different racial groups often handle drugs differently than the sort of typical Caucasian or white patient. Women may have different outcomes with regard to heart disease and so on.

But I think Don and I agree with regard to handcuffing. What concerns me is that there's a big difference between the House bill, as currently written, and the Senate bill. The House bill honors exactly what is Dr. Berwick and I have been saying, in that it -- it -- it makes sacred the judgment between doctor and patients, so-called informed, shared decision-making.

The incentives in the current Senate bill, to my mind, are potentially dangerous, because they basically pay people to follow what they say are best practices or evidence-based medicine is a very broad way. And that could easily lead to the doctor being in a position to coerce a patient to do something which the patient wouldn't really want to do or where the doctor disagrees with the guidelines; he thinks that the evidence is not compelling.

RAY SUAREZ: Dr. Berwick, how do you respond to that point about the effect that it would have to move evidence-based medicine to a more central role in the way we provide care and treatment?

DR. DONALD BERWICK: I have no question in my mind that we should move evidence-based medicine to a more central role, because, as I said, we have such evidence of really not very wise violations of adherence to what we do know. There -- there is a lot of chaos out there.

I think we have to be very wise about when we attach incentives to any particular form of care for an individual patient. I agree with Jerry that.

I would argue that there are some cases in which the -- the scientific evidence is so clear-cut for or against the use of a medication or a procedure that -- that it doesn't make sense to be rewarding behaviors on the part of any clinician that can -- that are harmful to patient -- patients. So, we have to attend to some form of increasing the stakes around the use of evidence properly, when it really does matter to patients.

Patients should use common sense

RAY SUAREZ: But how would it lower costs, Doctor?

DR. DONALD BERWICK: Well, this is -- there's a balance in our country between underuse of things that can help people and overuse of things that can't.

There are a lot of tests done, a lot of procedures, a lot of hospital admissions are done which we really know scientifically cannot help the patient. This isn't a matter of the doctor exercising good judgment. It's a -- it's a matter of people, for one reason or another, ignoring the evidence or not knowing about it.

My own opinion is, the balance is such that, if we did strict -- adhere -- adhere a little more closely to what we know, the overuse of unnecessary things would go down quite -- could go down quite substantially. Nobody would be harmed, and patients would be better off, subjected to less risk. And that should reduce costs.

There's debate about the balance, but I -- I think working hard on the overuse of ineffective practices is a very good way for us to save money and not harm a hair on a patient's head.

RAY SUAREZ: Well, that sounds like common sense, Dr. Groopman. How do you respond to Dr. Berwick?

DR. JEROME GROOPMAN: I agree in principle.

I think my focus, in terms of evidence-based applications where you can save quite a bit of money, actually comes from the kinds of initiatives that Donald Berwick has spearheaded. And those are safety initiatives.

There are huge sums of money with regard to patients entering hospital and developing infections within the hospital. This causes a great deal of suffering, sometimes death, prolonged admissions, and so on.

And, as Don says, there are procedures, in terms of how to safely put in an intravenous catheter and so on, where you can protect patients, and everyone agrees that you could save a great deal of money, you could spare patients harm, and there is no threat to patient autonomy.

But I think we have to be very, very strict around setting those barriers with the current legislation, because the evidence changes quite a bit once you move away from those kinds of safety measures and what are called cockpit rules, doing things in a careful, procedural way in the intensive care unit or in the emergency room.

RAY SUAREZ: Dr. Groopman, Dr. Berwick, gentlemen, thank you, both.

DR. DONALD BERWICK: Thank you, Ray.

DR. JEROME GROOPMAN: Thank you.

JUDY WOODRUFF: There's more about efforts to reform the health care system, including a recent interview with two former secretaries of health and human services, on our Web site. That's NewsHour.PBS.org.