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Health Care Reform’s Wild Card: The Uncertain Effectiveness of Comparative Effectiveness Research

effectiveness research (CER) stands out as the intriguing wild card
of health care reform. CER compares competing treatments against
each other to determine which interventions work best, supplying critical
information for medical decisionmaking and health policy. If CER
works as planned, it may be one of the few reform measures in the final
health care legislation that could flatten the cost curve while also
improving quality. Unfortunately, health care reform has so far
failed to bet smart and play the CER wild card effectively. While
the Patient Protection and Affordable Care Act invests in CER at record
levels and creates an entirely new regulatory framework for oversight
of the research, the new law does very little to advance the difficult
work of translating CER into actual medical practice. First, CER
is costly to conduct and its data often raise more questions than answers.
Second, the government’s CER agenda seems vague and ill-defined, not
consistently focusing on generating research that will help clinicians
resolve immediate treatment questions. Third, and most important,
physicians likely will remain indifferent to and
“tune out” CER. Health law and policy are not setting the
right incentives for physicians to adapt their practice patterns to
CER and, in some respects, exacerbate the physician-engagement difficulties.

The reasons for physician indifference to CER include:
lack of financial incentives, suspicions of industry bias in the public/private
oversight of the research, threats to clinical
autonomy, a commitment to individualized medicine (encouraged by health
law, professional ethics, and medical norms) that remains in tension
with CER, concerns that CER is a vehicle for crude cost-cutting, and
malpractice liability fears. To be truly effective, the new national
CER program requires targeted reforms designed to engage physicians
more directly with the research. This Article’s principal suggestions
include greater linkage of CER with reimbursement and liability incentives,
enhanced use of academic detailing, and more support for comparative
implementation studies that evaluate different strategies for fostering
physician uptake of CER.