Healthcare Town Hall

A recent Kaiser Health News (KHN) article highlights a theme we’ve written about previously: the convergence of quality and efficiency in healthcare. Here is an excerpt from the KHN article:

Treating a pneumonia case at the Theda Clark Medical Center in Neenah averaged $10,435 in 2008. Sacred Heart Hospital in Eau Claire, on the other hand, charged the average pneumonia patient $20,419, nearly twice as much.

What shocked hospital administrators most were the results for quality. Instead of higher cost hospitals delivering better care, the evidence pointed to just the opposite: The higher cost hospitals were less likely to meet benchmarks for quality. Theda Clark attained 95.5 percent of the quality goals outlined for treating a pneumonia case in 2008. Sacred Heart met just 90.5 percent of the standards.

Publishing the cost and quality data has had a far-reaching impact on the state, whose health care system is now considered among the best in the country. It gave hospitals with low quality ratings objective feedback for improving their performance. And the rankings motivated high cost hospitals to begin looking for ways to eliminate expensive but medically questionable procedures that didn’t improve outcomes.

Most important of all, it created a constituency – informed consumers – who were now armed with data that allowed them to pressure local hospitals to improve their performance. “People make purchasing decisions for everything from banking to refrigerators based on cost and quality information, but that is not how it currently works in health care,” said Walter Rugland, chairman of ThedaCare, at a House Energy & Commerce subcommittee on health hearing held last Thursday. “In Wisconsin, we believe we have fixed that problem.”

At least three bills introduced in the House this session but not included in health care reform would make a start on replicating the Wisconsin system nationally. But they don’t go far enough because they focus exclusively on price, and not on the quality side of the ledger.

Rugland spent much of his career at Milliman and is volunteer chair of four nonprofit hospitals in the ThedaCare network.

Efficiency, Quality of Care Convergence, ThedaCare, Walter Rugland

We have blogged before about how evidence-based medicine can help improve healthcare quality while also bringing about greater efficiency. But how do providers go about capitalizing on this unique convergence?

A new healthcare reform briefing paper by Milliman principals Patty Merola and Rodger Hopkins tackles this question by looking at the keys to success when implementing evidence-based guidelines in hospitals.

evidence-based medicine Convergence, hospitals, Patty Merola, Rodger Hopkins

Last night’s News Hour included an interview with doctor and essayist Atul Gawande.

He notes the disparities in American healthcare from one area to the next and calls for improvement in both quality and cost.

Cost, Quality of Care, Reform Atul Gawande, Convergence, geographic cost disparity

The latest Atul Gawande article examines how pilot programs in the Senate healthcare reform bill may help to moderate healthcare cost increases:

The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.

Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention—so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.

The bill has ideas for changes in other parts of the system, too. Some provisions attempt to improve efficiency through administrative reforms, by, for example, requiring insurance companies to create a single standardized form for insurance reimbursement, to alleviate the clerical burden on clinicians. There are tests of various kinds of community wellness programs. The legislation also continues a stimulus-package program that funds comparative-effectiveness research—testing existing treatments for a condition against one another—because fewer treatment failures should mean lower costs.

Looking for more reading on some of these concepts? Try these:

• Accountable care organizations
• Bundled payments
• Administrative improvement
• Research into effectiveness, convergence
• Wellness

Cost, Reform ACOs, admin, Atul Gawande, Convergence, Wellness

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.

Clearly, acquisition of high-quality evidence is essential to improving the quality of healthcare and reducing costly errors. Tools such as evidence-based guidelines exist to deliver the evidence to providers so they can easily use the information in clinical practice. Such guidelines can reduce the variation in care generated by differences in practice style, especially when uncertainly about the best treatment approach exists.

Independently developed, evidence-based guidelines can standardize the delivery of healthcare to best practices. This means that only efficacious treatments and tests are recommended, and only for patients likely to benefit from them. It also means that patients are treated in hospitals only for as long as needed, reducing the hazards of infections, falls, and medication errors. By recommending care for which there is evidence of appropriateness, and dissuading care that the evidence shows is inappropriate, providers can improve quality and efficiency at the same time.

Of course, acceptance of guidelines and wide implementation depend on providers’ confidence that the guidelines are developed by truly independent arbiters of what defines appropriate healthcare. To date, unfortunately, acceptance has been slow to develop. Thus, the promise of guidelines to influence practice style and change providers’ behavior has not been realized.

One reason for lack of acceptance is that the evidence base is incomplete, and multiple competing standards exist, leading at times to uncertainty about best care practices. A natural question to ask, then, is, “Are there ‘standards for the standards’”? How can policymakers, payors, and providers determine which guidelines and standards should be adopted? In response, guideline developers have created a set of standards, the AGREE instrument, by which to judge the quality of healthcare guidelines.

Cost, Efficiency, Quality of Care, Reform 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

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

Evidence has accumulated showing that more healthcare expenditures do not always mean better care. In some cases, healthcare interventions do not improve health. In other cases, they may worsen health, even to the point of causing death.

Clinical examples of this phenomenon abound. For instance, results of one large randomized trial conducted in the United States showed that screening for prostate cancer using blood testing for prostate-specific-antigen (PSA) plus digital rectal examination did not change the death rate from the disease. A European study, published on the same date, concluded that PSA-based screening reduced the rate of death by 20%, but at the cost of significant overdiagnosis. What should we take from these seemingly conflicting results? The first study suggests that prostate cancer screening has no benefit in terms of outcomes, and presumably is an inefficient use of healthcare dollars. While the second study may suggest some benefit, the 20% reduction is offset by the accompanying cost and risk of invasive diagnostic testing for men who do not have prostate cancer. Another way of looking at the results of the second study is that, in order to prevent one death, 1,410 men would need to be screened to find 48 additional cases of prostate cancer for treatment.

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Cost, Efficiency, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo