1756 health affairs october 2010 29:10 rom e edi or-in-c ie S omeday historians may gather to discuss cultural and eco- nomic trends in twenty-rst- century America. Tey will de- scribe an anomalous reality: a country living in what purported to be a scientic age, save for such tendencies as almost totemic devotion to much health care of little or no proven value. Let us hope these historians will be able to cite a turning point when this cult lost its hold on the nation. Perhaps one will unearth a photo of a corner- stone being laid for a new building: P-C O R- I, F MMX. As detailed in this thematic issue of Health Afairs, the institute was created under the Aordable Care Act to coordi- nate a major new national push on comparative eectiveness research. Te strategy ows from the novel concept that before we put patients at huge risk or incur new health care spending, we ought to have a reasonably good idea of how well the interventions work—espe- cially compared to diering treatments for the same condition, or (sometimes) for dierent subgroups of patients. fierce debate Federal funding in the amount of $1.1 billion was allocated for the research under the 2009 stimulus law (an ar- ticle by Joshua Benner and colleagues details how the money was spent). Tat spending paved the way for a erce debate over whether any additional backing for the research should be in- corporated into national health reform legislation enacted this year. As John Iglehart describes in this month’s Entry Point, Democratic lead- ers largely embraced the idea; many Re- publicans had previously been for it before they were against it. Meanwhile, fear that the research would lead to government rationing of care fueled the “death panels” fury of summer 2009. More legitimate worries arose from those who feared that the research would somehow defeat eorts to tailor therapies to individuals’ specic char- acteristics or genetic makeup. Such concerns were eventually al- layed, and the Patient-Centered Out- comes Research Institute was born as a paradoxically nongovernmental insti- tute with a government-appointed board of directors (names were an- nounced September 23, 2010). Dollars to carry out the research were to come primarily from a tax on health insurers. Now the “opportunities” side of the research ledger is bulging with options. As Alan Garber and Harold Sox point out, the legislation allows the eective- ness of not just individual treatments, but even entire programs to improve public health, to be compared. As the Institute of Medicine heralded, there is unprecedented opportunity “to assist consumers, clinicians, purchasers and policy makers to make informed deci- sions that will improve health care at both the individual and population lev- els.” In particular, care could be im- proved for minorities and other groups historically left out of much medical re- search, or for those with mental illness- es, as David Shern a nd colleagues from Mental Health America contend. Te “challenges” side of the ledger seems equally packed. Papers in this is- sue explore a number of them, includ- ing tactics and methodologies. Dave Chokshi et al. discuss such lessons as selecting appropriate “comparators,” lest the deck be stacked when one inter- vention is compared inappropriately to another. Once completed, the research must be disseminated in order to change health care practice. Jerey Lerner et al. thus propose a national pa- tient library of the research for use by clinicians and patients. the ‘r’ word Perhaps above all is the challenge im- posed by the health reform law itself, which imposed tight restrictions on what could be done with the research to avoid any appearance that it would lead to government rationing. Specically, Medicare was barred from using the re- search to establish cost-eectiveness of interventions or from drawing on such analyses in deciding whether and how much to pay for a given intervention. However, solutions are also put for- ward, such as Garber and Sox’s propos- al that “private parties” could perform cost-eectiveness analysis based in part on information published by the insti- tute. We can only hope that opponents of this idea won’t now be inspired to pass new legislation blocking o even this escape hatch to sanity. We sincerely thank the organizations whose sponsorship and support made this issue possible: the National Phar- maceutical Council, WellPo int Founda- tion, and Association of American Med- ical Colleges. o state the obvious, these organizations have an interest in advancing comparative eectiveness research, as do all Americans. As is cus- tomary, the sponsors had no role in the selection or editing of articles, and all content was peer-reviewed. n doi: 10.1377/hlthaff.2010.0900 Comparative Efectiveness: Coherent Health Care At Last? oct_from_the_eic.indd 1 9/23/10 3:43 PM