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 David Cundiff, MD: Bias Issues Inherent in Bravewell's Focus on Evidence-Based Medicine in Reform  
The following is one in an ongoing series of columns entitled Integrator Blog by . View all columns in series
Summary:In this response to the Bravewell Collaboration's listing of evidence-based medicine (EBM) and reimbursement reform as key factors in any healthcare transformation, David Cundiff, MD points out that "randomized controlled clinical trials and other tools of EBM are mostly funded by special interests and interpreted by researchers paid by those special interests." Thus "the evaluation of EBM trials is and will remain controversial." Cundiff, author Money Driven Medicine, argues that one-third of the HEDIS measures which shape insurer decisions on what get covered, are "highly questionable." Sponsors of these measures, Cundiff notes, include a who's who of major pharmaceutical firms. Can one even imagine a level playing field for an evidence-based inclusion of integrative, natural therapeutic approaches?

David Cundiff, MD
David Cundiff, MD, was first present in the Integrator in a column in which he took on the Cochrane Collaboration. (See
Cochrane Collaboration, High Court of Evidence-Based Medicine, Blasted for Bias in Medscape, June 22, 2007.) His core focus, then as here, is on controversies surrounding the objectivity of nominally objective evidence-based medicine (EBM).

Cundiff's book
In this column, Cundiff, author of Money Driven Medicine, focuses on two of the eight key factors in health reform which were listed by the Bravewell Collaborative following the recent Bravewell-funded Institute of Medicine Summit on Integrative Medicine and the Health of the Public.
(For the eight Bravewell factors, see Forum on the IOM: Bravewell's Post-Summit Statement on "Key Factors" in Any Health Reform Plan.) The two are use of EBM and the needed for reimbursement reform. Cundiff focusing on significant issues related to the value of the HEDIS outcomes which shape behavior of 90% of the nation's healthplans. He suggests that up to a third of their key indicators - the evidence upon which coverage of humans are shaped - "are highly questionable," providing evidence to back his assertions. This is stimulating, if despair-inducing, reading.

Challenges in Bravewell's Focus on Evidence-Based Medicine and Reimbursement as Reform Factors

David Cundiff, MD

Of the Bravewell Collaborative’s eight "key factors that should be included in health reform," six would probably appeal to the vast majority of stakeholders. However, the two factors that relate to allocation of resources present major challenges to finding a practical way forward with health care reform:
(1). Evidence-based medicine (EBM) is the only acceptable standard.  Researchers and practitioners alike concurred that health care should be supported by evidence and urged further research and testing to expand the evidence base for integrative models of care.

(2). The reimbursement system must be changed to a system that rewards outcomes rather than procedures with changes that incentivize physicians to focus on the health outcomes of their patients.
Let me address a major problem with basing medical resource allocation on EBM.

Sponsor of the HEDIS measures
Randomized controlled clinical trials and other tools of EBM are mostly funded by special interests and interpreted by researchers paid by those special interests. For that and other reasons, the evaluation of EBM trials is and will remain CONTROVERSIAL. Therefore, health care reform should not be predicated on being able to find the right, all-knowing, unbiased experts to draw up government-endorsed guidelines determining what interventions should and should not be covered by insurance.

For example, the National Committee for Quality Assurance (NCQA), a private, non-profit organization markets “Health Plan Employer Data and Information Set” (HEDIS), a tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and service. Employers, consultants and consumers use HEDIS data to help them select health plans. HEDIS data also are the centerpiece of most health plan "report cards" that appear in national magazines and local newspapers. Corporate financial sponsors of HEDIS include the following drug companies: Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc., McNeil Pediatrics, Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., Pfizer Inc., Daiichi Sankyo, Inc., Sanofi Pasteur, Abbott, Lilly, Bristol-Meyers Squibb, and Novo Nordisk.
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Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......moreJohn Weeks
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