Comparing Effectiveness

The NY Times magazine last weekend ran a lengthy interview with President Obama. Part of it deals with education and his opinions on education, but the most interesting passage was when the president is talking about health care. In it, he describes how, while a patient's involvement in their own care is a good thing, there are a lot of decisions that are best left to more knowledgable experts:

I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with himor go online to see if I can find a better opinion than his.

And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.

This seems to me like exactly the role the federal government should play. It should not dictate the actual decisions on the ground, but it should be able to provide information that leads to better decisions, especially in areas where it provides direct funding.

One of those areas is education. All districts must have math and reading curricula and a system for developing their teachers, but they lack good information on the effectiveness of their choices. They must base their decisions on company-produced studies, academic research, or, worst of all, local political calculations. Besides dangers of bias, research conducted by companies selling something often compare the effects of the treatment to the effects of doing nothing. Not surprisingly, something is usually more effective than nothing. Academic research tends to focus only on the general value of interventions, so it has something to say about phonics versus whole word reading instruction, new math versus old, or the general value of professional development. But it tends not to evaluate specific programs or interventions, or, if it does, the programs are boutique and unscalable. Not to mention the fact that academic research is buried in inaccessible journals and jargon.

Local decisions become a political parlor game. The math curriculum adopted is the one favored by a few teachers on some committee because they've found it useful in their classrooms, a sample size of one. The professional development plan shoved onto teachers is the one who had the best salesman to woo district officials. And so on.

The Institute for Education Sciences has begun edging towards comparative effectiveness research, releasing an evaluation of math textbooks and reading intervention programs in the last couple months, but we need much more. The US Department of Education spends a smaller percentage of its budget on research and development than any other federal agency, and it could do a lot more. It could be an influential voice to say, "you can pick whichever program you want, but here's some good information to inform your decision about which ones work and whether they merit their cost. And, oh by the way, we'll give you more money if you choose the ones that work best at the lowest price." Following the information will be left to local policymakers, but the federal government has a role in providing good information and nudging those decisionmakers into choosing wisely.

Comparative effectiveness research is not cheap. The stimulus bill provided the first-ever invesment in such research, and even its $1.1 billion appropriation will be only a beginning. Yet, it has potential to save much more down the road as our health care system erradicates inefficiencies. Such research is also not apolitical either, but neither are the decisions at the local level. Better to have a respected federal body to hear all the voices and make non-binding recommendations than have less knowledgable local actors making the same, under-informed decisions in 15,000 different districts.