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As more health maintenance organizations get involved in medical research, some health care buyers and physicians say that involvement may compromise the care HMOs provide.
HMOs' involvement with medical research was addressed in a series of articles in the July 16 issue of the Journal of the American Medical Assn. that questioned managed care organizations' willingness to pay for routine patient care as well as clinical research.
The question, according to some employers and physicians, is not where the money is coming from, but if managed care companies should participate in clinical research at all.
"Research has the potential for leading to considerably improved quality; that's why it's worth supporting," said Helen Darling, manager of international compensation and benefits for Xerox Corp. in Stamford, Conn. However, "there is just as much potential for doing harm."
There are two kinds of harm, she said. From the perspective of a health care buyer trying to select the most cost-effective plans, she is concerned that money spent treating terminal patients with experimental technologies may be diverted from the preventive screening and routine care of other patients who may achieve a much greater and longer-term health advantage from the procedures.
"If you look at a disease like cervical cancer, the women with the biggest problems come in too late," Ms. Darling said.
Second, aggressive treatment for some terminal diseases, such as cancer, also can put the patient at great risk, she said.
"Research has given us modern miracles," said Ms. Darling. "It's worth it, but there are tradeoffs."
Barbara Lardy, director of the medical affairs department for the American Assn. of Health Plans in Washington, said an investment in research is cost-effective in the long run.
"The overall research enterprise will benefit by working with managed care," Ms. Lardy said. "Research leads you to innovations (to find) the best way of providing care."
Ms. Lardy explained that when HMOs work with the National Institutes of Health, a key organization in funding medical research, the cost of the routine patient care associated with studies is covered by the plans themselves. The NIH provides the money to support the research side.
The question, she said, is "*'How do you define routine patient care?' That term often must be defined in the context of a particular patient," she said.
Some observers say managed care organizations should not fund any medical research.
"I don't know whether it makes sense to ask the managed care industry to solve the broader public problem of assuring adequate clinical research or medical education," said Dr. Arnold Milstein, medical director of the Pacific Business Group on Health, an employer purchasing coalition and a principal with William M. Mercer Inc. in San Francisco. "These
are broad national needs that need
to be systematically thought through and solved at a national levelrather than through exhorting the managed care industry to do more."
Steve Wetzell, executive director of policy and public affairs for the Buyers Health Care Action Group in Minneapolis, said research "isn't an issue just related to managed care. . .it's an issue of public policy and how we fund clinical research."
Mr. Wetzell said that while it is the coalition's policy to pay for treatment believed to benefit the patient, basic research should be funded with public money, not necessarily by health care plans.
"You still want to advance the science, and it takes money to (do so)," he said. "The problem is you don't know whether you're paying for something that will advance medical technology. How do you make the appropriate allocation?"
Dr. Milstein said, "Value improvement in health care lies not with progress in biotechnology, but rather in more consistently delivering the benefits of our existing technology."
He said the medical community does better at discovering new therapies than in learning how to utilize their potential benefit for the covered populations.
"We just don't pay any attention to delivery," Dr. Milstein said.
In the meantime, some managed care companies have initiated their own research programs. Several HMOs would not comment on their research.
Dr. Mary Durham, vp for research for Kaiser Foundation Hospitals in Portland, Ore., said Kaiser has been investing in research for the past 35 years.
"We have a great interest in doing research which identifies large groups of people, like women with breast cancer, or women with osteoporosis, or people with Alzheimer's," said Dr. Durham. "(Our research) is based on clinical trials, and many are large, randomized studies."
Kaiser "builds bridges" with academic medical centers, forming a partnership through which research can be performed, Dr. Durham said. She acknowledges that obtaining money is "much more difficult" nowadays. Of the $25 million Kaiser will spend on research this year, 60% comes from the NIH, about 30% is from private foundations, such as the Robert Wood Johnson Foundation, and Kaiser finances the remainder.
"I can't imagine anything else more cost-effective, especially something that's a social benefit as well," said Dr. Durham