Category Archives: Evidence-based medicine

Work absences and rheumatoid arthritis

Rheumatoid arthritis, estimated to affect 1.3 million adults in the United States, often results in disability and decreased work-related productivity. A new study by Jill van den Bos, Ksenia Draaghtel, et al., and published in the Journal of Health & Productivity, reviews the absence days and direct and indirect costs associated with rheumatoid arthritis for employees who received an anti-tumor necrosis factor (anti-TNF) agent compared to those who did not receive therapy.

See the full article here.

Evidence-based medicine and cancer treatment

A new article looks at how evidence-based medicine can help reduce the cost of cancer treatment. Here’s the situation:

The high cost of oncology is gaining a lot of attention these days. With cancer care accounting for ten percent of healthcare costs, payers are hungry to find ways to be more frugal. As oncologists, it is in our best interest, as well as the best interest of our patients, to take a proactive, leadership role in finding solutions that sustain our ability to deliver high-quality care.

OK, sounds good. How do we accomplish this? One idea:

A study by Milliman analyzing Medstat 2007 data revealed that out of those chemotherapy patients with 10 major cancer diagnoses who were identified as dying in an inpatient setting, 24% received chemotherapy within 14 days of death and 51% received chemotherapy within 30 days of death. While we cannot always predict when death will occur, pathways can help guide physicians in making decisions and treatment recommendations pertaining to whether to offer additional cycles of a treatment or move to second, third, and further lines of treatment. They can also provide practical guidance that can be helpful in end-of-life care discussions. This includes demonstrating that transitioning to hospice care can improve the patient’s and the family’s quality of life and can reduce the costs borne by the family and payers by avoiding unnecessary and ineffective chemotherapy administered within a few weeks of death.

Evidence-based medicine in India

The Indian healthcare system is at a familiar juncture. eHealth picks up on the story:

The size of the Indian medical technology industry may touch US$ 14 billion by 2020 from US$ 2.7 billion in 2008 on account of strong economic growth, higher public spending and private investments in healthcare, increased penetration of health insurance and emergence of new models of healthcare delivery.

Says Alam Singh, Assistant MD, Milliman India, “As the healthcare industry matures in terms of infrastructure and innovative technologies, the next goal of care delivery demands clinical excellence through evidence based medicine tools and benchmarks. Evidence based medicine is already being promoted globally and has been proved to be beneficial for all the stakeholders- clinical teams, hospital management as well as the patients. Evidence based medicine tools like clinical protocols and clinical pathways provide explicit and well defined standards of care for the clinical teams and support multi-disciplinary care planning.”

He further says, “From a management perspective these tools reduce healthcare costs, reduce patient documentation, optimise management of resources and help continuous clinical audit. They improve clinical care by delivering superior outcomes, improved clinical effectiveness and patient satisfaction.”

What is medical necessity?

Dennis Barry’s Reimbursement Advisor poses this question. Here is their answer:

Medical necessity is the determination that the level of care provided to a patient is appropriate and necessary to treat a patient’s medical condition and ensure a patient’s safety or health, such that a less intensive setting or service would jeopardize patient care. Medical necessity is documented by physician orders and outlined in local coverage and national coverage determinations.

Documenting medical necessity is required for Medicare to pay for the service. A service may benefit the patient, but it may not be a covered benefit if it does not meet medical necessity.

According to the Web site Payment Accuracy, “Approximately 99,500 claims were reviewed for the 2009 reporting period and the inpatient hospital short stays error rate was 12.4 percent, or $35.4 billion in estimated improper payments. The primary causes of improper payments were medically unnecessary services and insufficient documentation errors.” [See www.payment accuracy.gov.]

Short stays are a large-risk area for medical necessity inquiries. Providers must validate the necessity of short stay admissions. Providers cannot admit patients simply for the convenience of housing the patient overnight. Many short stays are found not to be medically necessary because the procedure or services provided could have been administered in an outpatient setting with no additional health risk to the patient. The fact that a patient was admitted only for a short period of time raises the question as to whether the patient should have been admitted at all.

Medical record documentation is essential to prove the validity of the claim. What is documented provides a clear directive for a medical necessity determination.

CMS considers claims medically unnecessary when they identify enough documentation to make an informed decision that the services billed were not medically necessary. This is based on Medicare coverage policies. An insufficient documentation error occurs when the provider does not submit sufficient documentation to determine whether the claim should have been paid.

The idea that medical necessity is driving some patients toward outpatient care is interesting to think about in the context of something we blogged about earlier this week.

“Most of the time”

A new article in the Milwaukee Journal Sentinel looks at evidence-based guidelines. Here is an excerpt:

[P]hysician societies, business groups, health insurers and consumer groups have called for more research on the effectiveness of different treatments. The results of that research should help doctors develop better guidelines – and better care for patients.

Despite the contention that it will lead to “one-size-fits all” care, comparative effectiveness research is a step removed from the guidelines themselves. The contention also ignores how guidelines are designed to be used.

“It’s a mistake to think of guidelines in black and white,” said Helen Blumen, a physician and managing editor of Milliman Care Guidelines LLC, which develops guidelines.

The words to live by, she said, are “most of the time.”

The science for developing guidelines is relatively new, and guidelines are far from perfect. The thousands that exist vary in quality and at times conflict. And a treatment that works equally well for all patients is rare.

But guidelines stillcan reduce the unnecessary variation in how doctors practice medicine and encourage them to follow what are considered best practices.

“The job of guidelines is to make it easy for physicians to do the right thing and hard to do the wrong thing,” Blumen said.

The compelling call for change is in patient outcome data

While there is broad consensus over the importance of evidence-based medicine in healthcare delivery, it is not always entirely clear what it means for a provider to implement evidence-based medicine. A new case study, “The compelling call for change is in patient outcome data,” tells the story of St. Jude Medical Center and how they adopted evidence-based practice care processes.