Healthcare Town Hall

Look for this interesting article in the upcoming weekend’s New York Times Magazine. The article looks at the progress of evidence-based medicine, the attempt to minimize variation in care, and specifically at Dr. Brent James from Intermountain Healthcare in Utah and Idaho. Here’s an excerpt (citing Dr. John Wennberg of the Dartmouth Atlas):

Wennberg, the Dartmouth researcher, argues that Intermountain is fundamentally different from other oft-cited models of high-quality, lower-cost care, like the Mayo Clinic and the Cleveland Clinic. These places, including Intermountain, share certain traits, like having a large number of doctors who receive fixed salaries rather than being paid piecemeal for each treatment. Partly as a result, these hospitals do fewer tests, treatments and operations than other hospitals and still get excellent results. What sets Intermountain apart, Wennberg says, is that it is also making a rigorous effort to analyze and improve bedside care.

“It’s the best model in the country of how you can actually change health care,” Wennberg told me. I heard nearly the same argument from Anthony Staines, a health scholar and hospital regulator in Switzerland who recently completed a study of some of the world’s most-admired hospitals. “Intermountain was really the only system where there was evidence of improvement in a majority of departments,” Staines said.

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Electronic Health Records, Evidence-based Requirements EHR, evidence-based medicine

What follows is excerpted from a recent healthcare reform briefing paper by Chad Karls, “Retooling Medical Professional Liability”: 

Clinical guidelines are not a new idea, but the idea of using them to shield doctors from malpractice lawsuits has gained some purchase of late. The idea is to establish a list of agreed-upon, evidence-based guidelines, which, if followed, would give physicians and other healthcare providers safe harbor from claims of malpractice. In addition, if physicians are in fact protected from medical negligence lawsuits provided they follow such guidelines, this could have an additional and significant benefit of reducing the level of defensive medicine that takes place.

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Evidence-based Requirements, Medmal, Reform Chad Karls, medical malpractice, Milliman Care Guidelines

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo. Today’s discussion continues where yesterday left off, explaining resistance to the convergence concept.

One of the major barriers identified in the NEJM study was physician resistance. In the hospitals surveyed, 36% of those who did not have an EHR stated that physician resistance was a barrier.34 Physicians resist the use of CDS tools for a variety of reasons, but the main reason is the belief that the use of an EHR and CDS tools will decrease clinical productivity and affect financial reimbursement. Other reasons range from not wanting a computer system to infringe on their decision making to something known as alert fatigue. Alert fatigue is when physicians have been exposed to poorly implemented EHRs that warn them continuously of possible problems as they access the system. Moreover, many of the CDS tools used today have been developed without clinician input, increasing resistance to their use. But if guidelines can be used to fine-tune EHR, and EHR can inform the creation of more user-efficient guidelines, what can emerge is a usability feedback loop that results in a self-improving system that avoids the dynamic of alert fatigue.

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Efficiency, Electronic Health Records, Evidence-based Requirements Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo.

Unfortunately, even when guidelines score well using the AGREE instrument, providers may still view them negatively. One example of this is an examination of guidelines conducted by researchers at RAND. One of the questions within the AGREE rigor-of-development domain requires that experts in both clinical content and guideline methodology who are external to the organization that has developed the guidelines review them, but it does not provide detailed specifications for the review. RAND researchers examined a set of guidelines for common, expensive diagnostic testing and treatment for musculoskeletal disorders of the spine and extremities. The researchers gave these guidelines high scores using the AGREE instrument. Then they asked a panel of providers (recommended by their specialty societies as leaders in their clinical field) to rate the relevance of the guidelines to common clinical situations and consistency with clinical understanding of existing evidence and expert opinion. The expert panelists thought that the guidelines did not address common clinical situations, and reported that they often disagreed with the experts’ interpretation of published evidence and clinical experience. In the face of findings of this nature, it is not surprising that guideline adherence in real-world situations may be imperfect, or that implementation of guidelines in healthcare systems may be met with resistance.

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Efficiency, Evidence-based Requirements, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency.” Click here to read the full paper or view citations.

The Appraisal of Guidelines Research & Evaluation (AGREE) instrument consists of 23 items organized into six domains, each of which captures a separate dimension of guideline quality. The domains are scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.

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Cost, Efficiency, Evidence-based Requirements, Quality of Care, Reform Convergence, Helen Blumen, Lynn Nemiccolo

What follows is excerpted from “The convergence of quality and efficiency,” by clinicians Helen Blumen and Lynn Nemiccolo. 

In contrast to how inappropriate care often leads to worse healthcare outcomes, there is evidence that appropriate healthcare leads to better outcomes. An examination of the use of tonsillectomy is a good example of the positive relationship between appropriateness and efficacy. Tonsillectomy is the most common surgical procedure performed in children, and a randomized, controlled trial has demonstrated its efficacy in decreasing the incidence of throat infection. These results justify the choice of tonsillectomy for children who met the very stringent eligibility criteria of clinical trials.

A subsequent clinical trial, conducted by the same researchers, considered children who were less severely affected by throat infections. This study found that both the control and surgical groups had relatively low rates of severe infection. And of those children treated surgically, nearly 8% had complications.

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Cost, Efficiency, Evidence-based Requirements, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo

Welcome to all readers, including those who have joined us from the Huffington Post after reading Deane Waldman’s latest article. We’ve included a copy of our post there from earlier today with various links to supporting materials.

Our post:

I’m part of the team that develops the Milliman Medical Index (MMI). We agree that healthcare costs are opaque and that the system is burdened by waste.

Two major factors affect healthcare costs. Reimbursement rates (how much is paid for a service or episode) and utilization (the volume of services). This year, utilization accounts for about one-fourth of the increase in our annual study, while the rest of the 7.4% cost increase is due to changes in reimbursement. But utilization remains a big deal. Talk of “reducing waste” requires smarter utilization. $700 billion a year in health costs is lost to waste. Of the “actual reasons for healthcare expenses” listed in Dr. Waldman”s article, some of the biggest sources of waste–action without evidence, inefficiency, perverse incentives, defensive medicine, and adverse outcomes and errors–result in overutilization.

Some of the top-performing care providers in the country have developed efficiencies that minimize poorly-coordinated utilization (misuse, overuse, or underuse that requires more care later). These providers’ efforts not only reduce costs but have led to better outcomes.

You could also lump “treatments available now that did not exist before” into the utilization bucket. While we continue to innovate, the cost of certain treatments has begun to exceed society”s ability to pay for them. Choices will have to be made. An effective, scientific understanding of outcomes will be an important part of that decision-making.

-Jeremy Engdahl-Johnson, Milliman Managing Editor

Cost, Efficiency, Evidence-based Requirements, Reform Cost, Huffington Post, Milliman Medical Index

This post is excerpted from the new paper by Jon Shreve, “Changing Expectations in Healthcare.”

Increasing access is not the only goal of real reform; improving overall quality and efficacy is also an important goal. Simply pumping more money–or people–into the present healthcare system does nothing to improve the underlying quality of care. Provider practices and patient demands that result in low-quality care are not only bad for the patients involved, they also force on all of us a kind of rationing driven by the inefficient use of resources.

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Evidence-based Requirements, Quality of Care, Reform expectations, Healthcare Reform, Jon Shreve

What follows has been excerpted from an essay by Jon Shreve, the first portion of which ran yesterday.

For many years, conventional wisdom assumed that barriers such as price or underwriting restrictions accounted for the large number of uninsured Americans. Remove the barriers, the reasoning went, and the problem would disappear. So there was reliance on subsidies to lower the entry cost to access—from government for low income individuals, from employers for employees, from the young for the old.

A number of states have introduced low-cost options for low income people (sometimes at four times the federal poverty level), only to capture a very low percentage of the uninsured. Even free expansions of Medicaid have often experienced take-up rates of only 60% or less. Others imposed restrictive rules on medical underwriting and/or community rating, with similar results—little change in the uninsured rates. Our own research of health consumer behavior shows that offering an affordable insurance option to the uninsured does not necessarily compel them to purchase insurance.

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Accountablity, Efficiency, Evidence-based Requirements, Quality of Care, Reform expectations, Healthcare Reform, Jon Shreve

What follows has been excerpted from a new paper, “Changing Expectations in Healthcare,” by Milliman Principal Jon Shreve.

Widespread evidence that our healthcare system is in need of substantial reform continues to mount. Most of this agreement centers on issues of access to affordable health insurance, the need to improve the quality and efficacy of care, and the costs associated with our present system. In order to achieve meaningful reform, a solution must address all three problems.

Of course this is easier said than done. While there may be general agreement on common goals for healthcare—increased access, improved quality, and reduced costs—there is no such agreement when it comes to how we accomplish these goals. If comprehensive healthcare reform is to occur, it should start with a clarification of the fundamental expectations for those involved in healthcare, and then incorporate policies designed to meet these fundamental expectations. Such expectations can help the healthcare system coalesce around interrelated responsibilities for patients, for care providers, and for payers.

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Accountablity, Cost, Evidence-based Requirements, Fragmented system, Quality of Care, Reform, Transparency expectations, Healthcare Reform, Jon Shreve