Sessions and Themes
- Shifting the paradigm: Vikas Saini
- Magical thinking and Modern medicine: Harvey Fineberg
- What makes us do it?
- What will it take to get us there?: Don Berwick
- What are the knowledge gaps in avoiding avoidable care?
- Case discussions
- What are the ethical issues?
- Medical journals and the issue of avoidable care
- The schizophrenic life of the hospital CEO
- A reason to change: Shannon Brownlee
- Social responsibility of physicians: Bernard Lown
- Behavior-changing Best practices
- Global dimensions of unnecessary care: Julio Frenk
- Payment mechanisms and the Culture of medicine
- Choosing wisely and beyond: What are the next steps?
- How can patients help drive the needed change?
Chuck Kilo, MD, MPH, Chief Medical Officer, Oregon Health & Science University
Understanding root causes for the provision of unnecessary testing, procedures, and treatments is necessary if we are to create effective solutions. The Institute of Medicine has listed 8 drivers for the overuse of resources – (1) malpractice, (2) patient demand, (3) poor evidence-base, (4) fee-for-service, (5) overcapacity of services and providers, (6) poor informed consent without shared decision-making, (7) gaps in education and training, and (8) society’s health culture.
These drives represent systems deficiencies amenable to intervention. Creating the right interventions is possible if we exert the right root cause analyses and subsequent leadership focused on positive system solutions. A key barrier to addressing these drivers is a healthcare culture that places blame externally (i.e., patient demand) while failing to accept responsibility and accountability for outcomes and performance improvement. Physicians and delivery system leaders the primary purveyors, stewards, and overseers of health services have a tendency to blame others for the health system’s performance instead of holding themselves accountable. They tend to blame insurers, the financing system, patients, politicians, society, and the government for healthcare’s poor performance and the provision of avoidable, low value services.
The culture of externalizing blame and poor accountability is evidenced by a lack of cohesive leadership across organizations that accept responsibility for clinical outcomes, patient experience, and the control of the total cost of care. Accountable leadership would seek to understand the drivers of low value, low quality care in order to create system solutions.
The 8 drivers have variable influence on different clinicians based on their personal belief system, training, knowledge of system design, communication skills, and other characteristics. In this session, we will analyze how much the 8 IOM drivers contribute to the overprovision of care. We will examine additional drivers including, for example, the lack of clear performance expectations for clinicians and healthcare leaders, poor accountability systems, and individual and industry tendencies to over-interpret the benefits of many healthcare services.
I’m delighted that discussion of the issue of avoiding avoidable care is beginning to happen. Its roots go back many years, and I would hope that no one is under the illusion that minimizing, let alone eliminating, avoidable care will be easy.
Beginning about 25 years ago, important work was done in this area by Bob Brook and his colleagues at RAND when they developed and applied the RAND Appropriateness Guidelines for various surgical procedures and invasive diagnostic procedures – e.g., coronary angiography, CABG, carotid endarterectomy, hysterectomy, and others. The RAND criteria were applied to a huge number of clinical scenarios that might lead to a particular procedure, and performing the procedure for patients with that scenario was then categorized as appropriate, uncertain, or inappropriate/unnecessary. A major problem was that very few instances were considered inappropriate/unnecessary – i.e., situations in which evidence or expert opinion indicated overwhelmingly that the risks outweighed the benefits. In the early 1990’s, reviews of patients who had coronary angiography in New York State and also at Harvard Community Health Plan, showed only about 6 percent of the procedures to have been “inappropriate” (Noonan SJ et al: Relationship of Anatomic Disease to Appropriateness Ratings of Coronary Angiography. Arch Internal Med 1995;155:1209-1213). Much larger percentages of persons undergoing such a procedure either were of “uncertain” appropriateness, 16 percent, or “appropriate,” 78 percent. A major question, however, is how many of the procedures are absolutely necessary – i.e., absolutely unavoidable. We do not have good evidence for knowing that, and I fear that we still have not put in place the necessary processes such as shared decision-making and large outcomes databases for gaining that evidence, which, by the way, for the most part will not come from randomized controlled clinical trials (Schoenbaum SC: Toward fewer procedures and better outcomes. JAMA 1993;269:794-796).
The point I want to emphasize is that if a discussion of avoiding avoidable care is limited to the relatively small number of things for which there is blanket evidence that they are always unnecessary, it will be a discussion of the top of the tip of the iceberg. I hope it will quickly become evident that a) we need to develop better evidence of what is necessary in what circumstances; b) we need to learn how to have difficult conversations with each other and with patients about what we do and do not know about benefits, risks, and costs; and c) we need to have difficult conversations among professionals about errors of omission, commission, and risks of malpractice in order to made significant inroads into avoiding avoidable care.
Heading the class in “Avoidable” is multi-level spinal fusion as a primary treatment for low back pain in patients with degenerative disc disease. Despite the many disclosures over the past few years in the press and medical journals regarding this important issue the surgeons participating in such excessive surgery have not yet been held accountable for their action, which thereby continues unchecked. Given the fact that poor behavior does not change unless there are significant consequences for it I would be most appreciative if this conference would spend some time discussing the issue of developing appropriate consequences and even more appropriately, effective behavior modifiers which would also make sense.
Be sure to check out Dr. Larson’s “Knowledge gaps” panelist presentation:
Knowledge Gaps Panel Presentation
Eric B. Larson, MD, MPH, Executive Director, Group Health Research Institute
Daniel R. Hoefer, MD, Outpatient Palliative Care and Hospice, Sharp HospiceCare
The vast majority of healthcare is paid for by a model called fee for service. The physician is paid once a procedure or event occurs. This became the foundation for Medicare reimbursement. At Medicare’s inception this was an acceptable model. Life expectancy was about 68 on average and the cost of care was limited by knowledge and relatively few available services.
Fifty years later however, technology and knowledge have dramatically increased. Unfortunately the culture of care and management of the elderly has not kept pace. (This includes the culture of reimbursement.) The fastest growing segments of the US population are over age 70 – 80. Yet, research historically deliberately excluded these demographics. We now know that the psychosocial needs of patients and families, goals of care and human physiology change as people live longer: http://www.nxtbook.com/nxtbooks/nhpco/newsline_201204/#/0.
We furthermore know that originally we had a reactive model of care, both medical and psychosocial. However, when 90% of patients in this country die from the predictable end stages of chronic illness a reactive model achieves inferior results. The hospital unnecessarily becomes a tool to manage late-stage disease.
Since 2007 Sharp Health Care through Sharp HospiceCare has embraced these changes. They have developed a model of transitional care which provides concurrent traditional and palliative management. Patients have complete access to traditionally aggressive treatment strategies but as their disease progresses can participate in aggressive palliative and then aggressive hospice strategies. The course of treatment is guided by the goals of care of the patient, including the fact that most persons do not want to be institutionalized and prefer to stay at home.
By providing a concurrent model of care patients have better quality of life, and their goals of care are respected at decreased cost. Hospitalizations are dramatically decreased. Caregiver and families as well have better outcomes. Sharp HospiceCare is decreasing the cost curve of healthcare, not by decreasing care but by dramatically improving the way it is delivered.
This informal panel aims to be a relaxed but provocative conversation with three hospital executives who are experiencing and managing a transition from fee-for-service and volume-based goals to focusing on value and effectiveness. We’ll hear about their worries and frustrations, as well as their successes, hopes and goals for the future as they push for a high-value delivery system.
We have three excellent members of the panel:
• Nancy Howell Agee, President and CEO, Carilion Clinic
• Jeanette Clough, CEO, Mount Auburn Hospital
• Peter Slavin, MD, President, Massachusetts General Hospital
Mount Auburn and MGH are both early adopters in population based care – both are CMMI Pioneer ACOs and both participate in BCBSMA’s Alternative Quality Contract. However, while early adopters they are both referral systems for Massachusetts and beyond meaning that they are in a high stakes transition from fee-for-service to population based value reimbursement models.
Carilion Clinic has chosen an different path. Deciding not to participate in CMS’s ACO efforts they are focusing on the private payer side to change the reimbursement model while continuing to develop their multi-specialty clinic model to meet the care demands of the future.
While I will use the moderator’s prerogative to probe the risks and benefits of this transition if needed, I would prefer to have this panel be an open forum with the discussion driven primarily by members of the audience.
I look forward to seeing you all this week.
Be sure to check out Shannon Brownlee’s recently published story, “The Doctor Will See You-If You’re Quick”, available online at the Daily Beast and in this week’s Newsweek Magazine.
Dr. Vikas Saini and Dr. Christine Cassel, president and CEO of the American Board of Internal Medicine Foundation, participated in a segment on WBUR called Doctors target overtreatment and avoidable care.
[An excerpt from the WBUR website] Here in Massachusetts, with global payment systems gaining traction, the idea that more health care doesn’t exactly mean better health care isn’t entirely new.
And with the rising cost of health care, targeting wasteful spending is something almost everyone can get onboard with. But once you start getting specific — that is to say, start talking about this test or that treatment — that’s when you run into trouble.