Just what so many people feared: comparative effectiveness research (CER) is really a metaphor for comparative payment and -- (dum-da-dum-dum) -- rationing! But, wait a minute. It doesn’t have to result in rationing... what if it was a rational way to create fair payment?

In other words, if the science for CER was considered reliable, evidence-based, and patient-centered (including having a balance of gender, ethnic, and pediatric patients included, for example), then why not pay for interventions and services with better outcomes, and equivalent pay for different services with comparable outcomes?

In the latest edition of Health Affairs, Steven Pearson and Peter Bach propose a novel approach to re-calibrating Medicare payment. Pearson is president of the Institute for Clinical and Economic Review at Massachusetts General Hospital's Institute for Technology Assessment. Bach is an attending physician at Memorial Sloan-Kettering Cancer Center in New York City and a former adviser to the CMS Administrator.

Pearson and Bach note that the Affordable Care Act (ACA) puts strict limits on the ability of the federal government to draw on CER to determine what can be covered under Medicare. But they believe that using well-performed CER to determine how much to pay for newly covered services could yield billions of dollars in savings without threatening patient choice. This really is worth considering. But note that the new PCORI (Patient Centered Outcomes Research Institute), upon which ACC Trustee Harlan Krumholz sits, is precluded from determining payment methodologies.

Under the three-pronged model set forth by Pearson and Bach, Medicare would pay more for interventions that research had demonstrated provided superior results for patients. By the same token, when two interventions demonstrated comparable clinical effectiveness, Medicare would pay the same amount for both. When a new service or treatment lacked any comparative evidence, Medicare would set a tentative payment while research on the intervention's effectiveness was carried out. After three years, if there was no clear evidence that the new service had a clinical advantage over an alternative intervention, Medicare could reevaluate what it would pay for the service.

For new CV interventions (TAVI, Ablation, cell therapy, etc) coverage with evidence development (CED) using registries could accelerate getting data needed for such CER research! We have the registries.

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