"That's good, but certainly we know that there are a lot of other payers besides Medicare," says Peggy L. Naas, MD, MBA, vice president of physician strategies at VHA Inc., an Irving, TX-based national healthcare network. "So this may certainly influence coverage. Is that bad? It depends on the research on which it's based."
What's going to be interesting for hospital leaders is whether, like EBM guidelines, CER can help in capital decision-making, common order sets, and decisions about what services to offer on an inpatient basis, Naas says. How does the hospital that follows CER make judicious decisions about capital and physician and other staff training?
"What if hospitals invest in eye surgery suites, for example, and then research suggests a pill that could treat an eye malady where once surgery was the only option?" asks Naas. "That research becomes the basis for reimbursement denial." Multiply that one decision across an entire health system and the uncertainty with which leaders view CER becomes much more clear.
Room for outliers
Smart implementers of EBM programs allow for physicians to make individual patient decisions that diverge from EBM guidelines, says HealthGrades' Rick May, MD, senior physician consultant.
"The beauty of the way the system works is that because the docs are so busy, if you give them an easier path to choose, they'll choose that path unless they truly have reason to believe that patient would do better under a different treatment plan."
May is quick to say that integrating comparative effectiveness research into reimbursement and treatment plans is premature when physicians provide care that follows evidence-based guidelines only "about 50% of the time or less. The point is that evidence is out there, but we don't use it when it's available and it's a slow adoption curve."
May says an estimated 17-year differential exists between the time evidence is found in medical research to support certain treatments and its being adopted into clinical practice, so the idea of forcing the issue and shortening that timeline through reimbursement restrictions has merit, he says.
"Systems need to make it as easy as possible for physicians to default to EBM."