It's been tried before, with arguably disastrous and lingering consequences. Managed care, a creation of health care insurers, sought to control costs by reducing use of specialists, equipment and costly tests. It frustrated doctors and alienated consumers. An ultimate backlash fed freewheeling care choice.
Leaders of the American Hospital Association's appropriate use of medical resources initiative say that's not likely to happen in this day and age. One reason is that clinicians and consumers are being courted, informed and brought into the loop at the outset.
"The contrast with 20 years ago is that this feels more like a partnership between the provider and the payers … as opposed to something the payers are doing to the providers with inadequate knowledge of the clinical context," says Ken Sands, M.D., senior vice president for health care quality at Beth Israel Deaconess Medical Center, Boston. Another difference is "acknowledgement now of the need to preserve quality and outcomes, which I think wasn't part of earlier constructs [that] were simply to reduce utilization without a lot of attention to whether quality outcomes were being preserved or not."
Like many networks, Franciscan Health System is out to reduce total cost of care in part by developing a clinically integrated network. With all clinicians working from one electronic health record and following agreed-on clinical pathways and practice standards, the data-driven norm is more favorable to scrutiny of medical choices backed by empirical evidence and monitored in objective review of physician action as recorded in an EHR, says Mark Adams, M.D., chief medical officer of the Tacoma, Wash.-based system.
Tracking the care given by health care professionals helps to hold them accountable to known measures and practices. If a provider is working outside the care pathway, medical and administrative leaders learn about it and can insist on adherence, "to the point where they may be excluded from the network," Adams says. But 95 percent of the time, a physician who is shown data will self-correct. "For those who don't or can't, they can't participate," he says.
Ochsner Health System's two-year-old Pursuit of Value program concentrates on optimal medical care intended to produce positive outcomes with the least amount of harm, the value measured by what patients are put through and the effect on their financial, work-related and personal lives, says William Pinsky, M.D., executive vice president and chief academic officer of the New Orleans system. A physician and administrator jointly manage it, and physician champions in every medical specialty carry the program to the patient care level.
"The rhythm that is going on in health care right now, in terms of involving physicians as one of the [groups of] leaders in these initiatives and these endeavors, is really a positive thing," says Pinsky. "For organizations like Ochsner, Mayo Clinic and so forth, where we've always been physician-led, this is an extension of what we've always done. Now, I think the rest of the community is seeing this as well. That's going to be positive for patient care."
What the business world calls demand management has to involve not only clinician inclinations, but also patient requests. On antibiotic demand, for example, "It's quicker and in some ways will be perceived by the patient as more favorable if you say, 'Yes, here you go, here's an antibiotic' as opposed to taking the long route to explain why they don't need the antibiotic," Sands says. "It takes coaching, and takes the ability to explain these things to patients." There is also a need for greater public awareness of the risks compared to the benefits, "which can be negligible in a lot of cases."
Current initiatives have a better chance of success because consumers are involved in the formula. That includes the partnership of the ABIM Foundation's Choosing Wisely initiative's with Consumer Reports, which has layman versions of the reasoning behind potentially useless or harmful tests and practices, says Scott Weingarten, M.D., senior vice president and chief clinical transformation officer at Cedars-Sinai Medical Center, Los Angeles. "It's very helpful for a physician who is advising a patient that a particular treatment may provide more harm than benefit, or may provide minimal or no benefit, to give the patient information so that the patient may make an informed decision about what is best for his or her health care," he says.
Part of the culture change is becoming comfortable with not always having the answer, says Elisa Arespacochaga, director of the AHA's Physician Leadership Forum. "It's discomfort with ambiguity," she says. "We are no longer comfortable with not being in the know. So when someone's presented with an 'I don't know' in medicine, there's pressure to find out as much as possible. We need to shift to a culture where we all ask, 'If we know the answer, is it going to change the course of treatment?' "
Unproductive tests shouldn't come as a surprise. Nearly 25 years ago, Weingarten conducted a study while at a Kaiser Permanente facility in California on CT scans performed on patients who had chronic isolated headaches but no cancer, trauma or neurological symptoms. Of an adult population exceeding 100,000, "none of the scans provided clinically useful information," and some were false positives that caused either needless anxiety during follow-up periods or unnecessary procedures such as brain biopsies, he says.
Due to advanced screening capabilities there has been a rise in incidental findings on imaging and laboratory studies that add to the overdiagnosis of disease, says John R. Combes, M.D., AHA senior vice president and chief operating office of AHA's Center for Healthcare Governance. "It's sort of technology without wisdom. Our technology enables us to see a lot of things, but not necessarily to advance our understanding of what we see." What often happens are more workups to discover more about the scan finding, more interventions and increasing risk for the patient, which may have no effect on the person's health and well-being, he says.
Sometimes simple procedures combined with technology can help doctors to avoid unnecessary or unwanted care. Beth Israel Deaconess, for example, is improving its system for collecting and using advance directives to better govern end-of-life care, says Sands. That would include more judicious use of the intensive care unit for terminally ill patients, one of the five areas in the AHA appropriate-use campaign.
"We think that we can be more attentive to people's wishes, and [that] we are sure that those conversations occur as they should, and occur proactively," he says. "And that when those conversations do occur, we are sure to capture them as part of the EHR and that we are sure that we act on those appropriately — all things that the medical system hasn't traditionally done well. Ultimately, it will allow us to more proactively follow people's wishes and eliminate some unnecessary end-of-life care."
For more on the genesis of the AHA's appropriate use of medical resources initiative, see our April cover story, "Is It Worth the Risk?"
John Morrissey is a freelance writer in Mount Prospect, Ill.