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.
These drivers obviously interact in complex ways to influence clinician and leader behavior. The results include health care resources irrationally distributed compared to social need, a common professional ethos of “doing” up to the limit of resources, and the failure of patient agency. These factors bias towards unnecessary care for some, while leaving others without the care they need.
The answers are in our leadership and system design informed by these drivers. For instance, that some clinicians respond to the fear of malpractice by providing unnecessary tests and procedures suggests the need to help clinicians understand more effective approaches to managing uncertainty. Malpractice claims are most frequently driven by poor communication, poor access, faulty follow-up systems (i.e., lack of appropriate reminder systems), and the failure to diagnose. Some might believe that the provision of diagnostic tests addresses the “failure to diagnose” problem for instance, but “failure to diagnosis” is largely resolved through careful, thorough history taking and a rational, judicious approach to diagnosis, not through unnecessary tests and procedures. Addressing malpractice as a driver of overuse can be achieved through training and practice design assistance that addresses true drivers of malpractice risk while assisting clinicians in managing uncertainty.
Our goal is to analyze the drivers in order to create specific positive system solutions that mitigate their effects.