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Thursday, November 19, 2015

We Need to Know What Works in Health Care

Caitlin Morris

Director of Affordability Initiatives

Almost everyone will be faced with the need to make a critical decision about treatment for a disease or medical condition at some point in our lives. If you’re diagnosed with diabetes or heart disease, for example, you’ll want to make sure that you get the best care possible. In that moment, many will ask: What’s the right treatment option for me? 

The answer to that question may not be as simple as we might like or expect. Medical evidence is the foundation for determining what works, and for whom, in health care. And for informing decision making. Stakeholders across the health care spectrum—from patients and providers to payers and regulators—rely on medical evidence. Both public and private payers evaluate medical evidence in determining what health care services to cover, and providers and patients use evidence to determine a course of treatment.

Lack of evidence hinders decision making across the health care spectrum

Unfortunately, we don’t always have the evidence we need or want to help inform critical decisions. By some estimates, only half of all care received is based on current best evidence. Often, the evidence we do have may be incomplete or inconclusive. This is particularly true for certain populations, like racial and ethnic minorities or people with multiple comorbidities. And, even in situations where there is ample evidence to point to what works, there’s no guarantee that consumers will actually receive that care. 

These gaps and challenges hinder decision making across the health care spectrum. For consumer advocates working on health care issues, these challenges related to evidence-based decision making are of particular concern: A lack of understanding about what works in health care makes it difficult for patients and consumers to receive both necessary information and the health insurance benefits that secure them access to needed services.

What does high-quality medical evidence look like? 

To help ensure that consumers have access to high-quality, affordable, and timely health care, we must begin by answering that critical question: What works and for whom? This, in part, requires a focused effort by the research community to build an evidence base necessary to answer that question. Several components of high-quality medical evidence are essential to this endeavor. For example, medical evidence should:

  1. Compare all relevant treatment options: Often, treatment options for a disease or condition may include a diverse set of interventions—from surgery to pharmaceuticals to medical devices. Medical evidence must be comparative, which means it should answer the question: How well do each of these options fair against the alternatives? 
  2. Consider cost: There is a limited relationship between the cost of a treatment or intervention (both to the system and to the consumer) and how effective that option is for patients. Medical evidence must consider cost in order to put clinical effectiveness into context and identify treatments and interventions that are truly high-value. 
  3. Represent diverse populations: Too little is known about the effects of treatments and interventions on different populations, particularly communities of color that are frequently underrepresented in clinical research. We must ensure that medical evidence accurately reflects the experience of diverse populations. 
  4. Answer questions that matter to patients: Researchers and patients often view the world differently. What may be an important outcome for a researcher may not register as important at all for patients. It’s critical that medical research incorporate patients’ needs, values, and preferences to ensure that evidence truly speaks to what patients care about the most. 

Improving medical evidence is important for broader system reform efforts

As important as high-quality medical evidence is for patients and their doctors, it also has critical applicability for broader efforts to improve how we pay for and deliver care. 

Health system transformation efforts: Figuring out what works can help efforts to tackle pressing issues in our health care system. For one, medical evidence is essential for sparking a national conversation about value. With rising health care costs increasingly crowding out other essential services, we can no longer afford to treat all heath care services as equal. If we hope to move our health care system from volume to value we must be able to identify what value means in the American context. This starts with an understanding of what works.

Patient safety and health equity: Good medical evidence is also essential for improving quality and ensuring patient safety. When we know what works, we can equip and incentivize providers to deliver high-quality care. This, in turn, serves to minimize patient harm caused by inappropriate or unnecessary care. Furthermore, figuring out what works can have an important impact on health equity. Research suggests that when providers equitably deliver evidence-based care it can lead to a significant reduction of disparities in health outcomes for certain diseases and conditions.

Access to and affordability of essential health care: We also cannot ignore the role that medical evidence can play in increasing access to, and ensuring the affordability of, essential health care services.  As consumers are being asked to bear more and more of the burden of rising health care costs through high deductibles and increased cost-sharing, we must continue to push for access to affordable, high-value services. Innovative benefit designs, like Value-Based Insurance Design (VBID), are one way to help ensure that consumers can get the health care we know works. 

Good medical evidence is the foundation of determining what works in health care, and pushing a national conversation about the differences in value of medical treatments, test, and interventions. Our next blog in this series will look at some of the organizations and activities involved in determined what services are high value services.