American Medical Student Association

by Ken Williams
Graduate Special Student
The Johns Hopkins University Bloomberg School of Public Health

Lately, I have had a lot of people ask me about the difference (if there is one) between comparative effectiveness research (CER) and cost-effectiveness analysis (CEA), so I thought that I would take this opportunity to provide a very brief introduction to the subject.

The American Recovery and Reinvestment Act (ARRA) created the Federal Coordinating Council for Comparative Effectiveness Research (Federal Council), which is charged with coordinating the research and guiding the allocation of the money invested in CER by ARRA. In all, $1.1 billion USD has been earmarked for CER with $300 million going to the Department of Health and Human Service’s (HHS) Agency for Healthcare Research and Quality, $400 million for the National Institutes of Health, and $400 million for the Secretary of HHS. With this amount of money on the line, CER has become a very hot topic here inside the beltway.

While there are many definitions of CER out there, the Federal Council, in a report to the President and Congress, provides the following, which serves as an overall guiding definition for the entire federal government:

Comparative effectiveness research is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat and monitor health conditions in “real world” settings. The purpose of this research is to improve health outcomes by developing and disseminating evidence-based information to patients, clinicians, and other decision-makers, responding to their expressed needs, about which interventions are most effective for which patients under specific circumstances.

• To provide this information, comparative effectiveness research must assess a comprehensive array of health-related outcomes for diverse patient populations and sub­ groups.
• Defined interventions compared may include medications, procedures, medical and assistive devices and technologies, diagnostic testing, behavioral change, and delivery system strategies.
• This research necessitates the development, expansion, and use of a variety of data sources and methods to assess comparative effectiveness and actively disseminate the results.

That is, CER takes evidence-based data about different interventions and seeks to determine the benefits and harms of each as compared to each other.

One of the most important things to notice about the list is that it does not ever mention cost. This is where most of the confusion sets in. In the US, the official CER guidelines, as presented by the Federal Council, do not take cost into consideration as a factor. This is not the case universally, however, as other countries, sub-national governments, and organizations do list CEA as an important component to CER.

As compared to CER, cost-effectiveness analysis (CEA) is entirely focused on the costs of medical and public health interventions. Specifically, CEA will calculate the cost per some measurable improvement (or decline) such as quality-adjusted life years or disability-adjusted life years or the like. While CEA is not included as part of the official US CER guidelines, it is still important to note that CEA can provide valuable supplemental information for decision makers.

By Ken Williams

As you surely know, Medicare reached its 45th anniversary recently. It has done a lot in those few decades to help improve health care in America and to reduce health disparities across racial and ethnic divides. Medicare is most known for guaranteeing health coverage for Americans over 65, but it was also a key driver in a variety of other health care innovations – including the desegregation of hospitals. Although Medicare does a lot to ensure that we, as a nation, are able to provide medical care to many of those most in need, its future is uncertain.

Amid tales of impending financial failure, Medicare has found itself potentially on the chopping block. This December, the National Commission on Fiscal Responsibility and Reform (aka the Deficit Commission) will meet to vote on recommendations to reduce the federal deficit, including such drastic measures as reducing Medicare benefits. The American Medical Student Association (AMSA) believes that it is imperative to make our voices heard: we cannot support any bill that will limit our patients’ access to quality, affordable health care. Indeed, we believe that the real solution is not to reduce or eliminate Medicare, but is, instead, to expand Medicare’s coverage to ALL those living in America.

AMSA believes that the expansion of Medicare would hold many benefits for America, not just in terms of the nation’s physical and mental health, but also in terms of our financial health. By expanding and improving Medicare, we can shift the focus of our health care system from the failed for-profit structure that has caused many of our fellow Americans to find themselves in bankruptcy (a 2009 Harvard study found that over 62% of all bankruptcies result from massive medical bills, a 50% increase over the 2001–2007 period) to a system built around preventive primary care and wellness.

AMSA believes that the right approach is to:

• Expand Medicare and "buy-in" options as steps toward improved Medicare-for-all;
• Protect access to care by limiting out-of-pocket expenses for Medicare beneficiaries; and
• Find a permanent solution to the sustainable growth rate (SGR) that appropriately incentivizes primary care and provides adequate compensation to maximize provider participation in the Medicare program.

These and other improvements are the real solution for America’s physical, mental, and fiscal health. For-profit health care is already leading to higher numbers of uninsured Americans, increased bankruptcy rates, and an inflated national deficit. It is time that we look to real solutions such as Expanded Medicare-for-All (H.R. 676), rather than reducing a program that already provides so much to our country and our fellow citizens.