When evidence becomes politicized, how do we talk about low-value care?
“They gave me Regeneron and it was like unbelievable, I felt good immediately….I call that a cure.”President Donald Trump, October 7, 2020
Throughout the Covid-19 pandemic, President Donald Trump has touted unproven remedies, both before and after he was diagnosed with the disease. His rhetoric sends the message to Americans that we don’t need to wait for clinical evidence before declaring that something works and waiting for evidence would unjustly deprive people of access to cures. In this framework, a single positive response to a new treatment is the same as a “cure,” and making unproven treatments available to everyone is the same as “equality.”
Even though President-elect Joseph Biden is planning a different approach to the Covid-19 pandemic, the injection of partisan politics into discussions of clinical effectiveness could have a lasting impact, making efforts to reduce low-value care more difficult (low-value care refers to health care services that offer little or no clinical benefit). Decisions involving clinical evidence with multiple stakeholders have always been political, but they generally involve specific health care groups representing their interests. As debates on evidence and effectiveness have moved more into the public view, discussions around these decisions have taken on a political tinge, to the point where they fall along party lines.
In this framework, a single positive response to a new treatment is the same as a “cure,” and making unproven treatments available to everyone is the same as “equality.”
As researchers and advocates for safe and effective care, we see the need for the “Less is More” movement to anticipate this potential division and reframe our message to improve public and bipartisan political support. We want the public, the media, and policymakers to understand that high-value care is as much about freedom from harm as it is about cost and efficiency.
More than a decade’s worth of research on low-value care has given the medical field a solid understanding of the widespread prevalence of overuse and its cost to the health system. Less well understood is the rate of preventable harm it causes to patients, but there is widespread agreement that the harm is not negligible. Despite the cost and harm, large and lasting reductions in overuse have been elusive.
If clinical evidence becomes a political — or worse — partisan issue, creating such a coalition and achieving needed reforms will be increasingly difficult.
To create a health system that avoids low-value care, we need significant changes in health care policy, as well as a cultural shift away from the “more is better” default. That will require a broad coalition of clinicians, patients, and policymakers. If clinical evidence becomes a political — or worse — partisan issue, creating such a coalition and achieving needed reforms will be increasingly difficult.
President Trump’s statements have already fueled public demand for unproven Covid-19 treatments. In the days after Trump claimed that he was “cured” by the Regeneron antibody cocktail, leaders of the clinical trials reported receiving more requests from patients to participate. Researchers found similar effects after Trump touted the curative effects of hydroxychloroquine, a drug that was later found to be harmful, and convalescent plasma.
Increased public enthusiasm for experimental treatments could create hurdles for helpful policies. One effective way to reduce low-value care is to stop reimbursing clinicians for these services. But if the standard for patients and clinicians becomes “one good outcome,” no service will ever be off the table. And if industry, hospitals, and other institutions reap financial and political gains from selling unproven therapies, they will fight against policies to reduce low-value care.
This has concerning implications for future administrations’ efforts to increase health insurance coverage, because expanding access to care will be nearly impossible if the public demands that all services be covered. Additionally, those who oppose the efforts to expand health insurance will likely use demand for unproven treatments as a weapon to attack single payer, by saying that a public health plan would restrict patients’ “freedom of choice.” The more political and health care industry interests converge around this message, the more difficult it will be to move toward affordable universal health care.
We want Americans to think about high-value care as a movement for saving lives, rather than saving money.
If we want systemic change, we need to review how clinicians, policymakers, and the public view value in health care. Avoiding overuse may be seen as just a cost-saving measure, when it is as much about preventing harm to patients. Our goal is for Americans to think about high-value care as a movement for saving lives, rather than saving money for the government and insurance companies. To that end, we should focus on framing high-value care as “freedom to receive the best care without fear of harm.”
This will require engaging the media, policymakers, and the public on the potential for low-value care to hurt patients. For every celebrity’s story in the popular media about an unproven medication or cancer screening that “saved my life,” we need another celebrity sharing a story of overtreatment. When politicians say they will protect our “right to try” unproven treatments, we need them to also say how they protect our freedom from unnecessary harm.
Rather than just telling the public to “listen to the experts,” we should empower people to think critically about claims they hear about new medical treatments (as well as the people making these claims), and give them the tools they need to do so. At the same time, clinicians should be empowered to objectively evaluate the treatments they use, and to see their job not just as serving patients, but also protecting them from unnecessary interventions.
The pandemic gives us an opportunity to change the conversation, to make high-value care an essential element of what we consider health care quality, safety, and even freedom.
The Biden administration will need to address the political divide around low-value care, and do so quickly and clearly, in ways that acknowledge the sense shared by too many Americans that they are being shut out from care that could help them. They should avoid the temptation to create hype around untested treatments, be it new Covid-19 treatments or a cure for cancer.
Many of us in the health care field are alarmed by the increasingly political rhetoric that has developed around clinical evidence in the Covid-19 era. Yet the pandemic also gives us an opportunity to change the conversation, to make high-value care an essential element of what we consider health care quality, safety, and even freedom.
Judith Garber and Shannon Brownlee also contributed to this piece.