Pretty much everyone agrees that we need to improve the quality of healthcare delivered to patients. We’ve all heard the frightening statistics
from the Institute of Medicine about medical error rates – that as many
as 98,000 patients die each year as a result of them – and we also know
that the US spends about 33% more than most industrialized country on healthcare, without substantial improvements in outcomes.
However, a large number of quality improvement initiatives rely on
additional rules, regulations, and penalties to inspire change (for
example, decreasing Medicare payments to hospitals with higher
readmission rates, and decreasing provider compensation based on quality indicators).
Not only am I skeptical about this stick vs. carrot strategy, but I
think it will further demoralize providers, pit key stakeholders
against one another, and cause people to spend their energy figuring
out how to game the system than do the right thing for patients.
There is a carrot approach that could theoretically result in a $757
billion savings/year that has not been fully explored – and I suggest
that we take a look at it before we “release the hounds” on hospitals
and providers in an attempt to improve healthcare quality.
I attended the Senate Finance Committee’s hearing on budget options
for health care reform on February 25th. One of the potential areas of
substantial cost savings identified by the Congressional Budget Office
(CBO) is non evidence-based variations in practice patterns. In fact,
at the recent Medicare Policy Summit, CBO staff identified this problem
as one of the top three causes of rising healthcare costs. Just take a look at this map of variations of healthcare spending
to get a feel for the local practice cultures that influence treatment
choices and prices for those treatments. There seems to be no
organizing principle at all.
Senator Baucus (Chairman of the Senate Finance Committee) appeared
genuinely distressed about this situation and was unclear about the
best way to incentivize (or penalize) doctors to make their care
decisions more uniformly evidence-based. In my opinion, a “top down”
approach will likely be received with mistrust and disgruntlement on
the part of physicians. What the Senator needs to know is that there is
a bottom up approach already in place that could provide a real win-win
Some 340 thousand physicians have access to a fully peer-reviewed, regularly updated decision-support tool (called “UpToDate“)
online and on their PDAs. This virtual treatment guide has 3900
contributing authors and editors, and 120 million page views per year.
The goal of the tool is to make specific recommendations for patient
care based on the best available evidence. The content is monetized
100% through subscriptions – meaning there is no industry influence in
the guidelines adopted. Science is carefully analyzed by the very top
leaders in their respective fields, and care consensuses are reached –
and updated as frequently as new evidence requires it.
Not only has this tool developed “cult status” among physicians – but some confess to being addicted to it,
unwilling to practice medicine without it at their side for reference
purposes. The brand is universally recognized for its quality and
clinical excellence and is subscribed to by 88% of academic medical
In addition, a recent study published in the International Journal of Medical Informatics found
that there was a “dose response” relationship between use of the
decision support tool and quality indicators, meaning that the more
pages of the database that were accessed by physicians at participating
hospitals, the better the patient outcomes (lower complication rates
and better safety compliance), and shorter the lengths of stay.
So, we already have an online, evidence-based treatment support
guide that many physicians know and respect. If improved quality
measures are our goal, why not incentivize hospitals and providers to
use UpToDate more regularly? A public-private partnership like this (where the government subsidizes subscriptions for hospitals, channels comparative clinical effectiveness research findings to UpToDate staff, and perhaps offers Medicare bonuses to hospitals and providers for UpToDate
page views) could single handedly ensure that all clinicians are
operating out of the same playbook (one that was created by a team of
unbiased scientists in reviewing all available research). I believe
that this might be the easiest, most palatable way to target the
problem of inconsistent practice styles on a national level. And as
Senator Baucus has noted – the potential savings associated with having
all providers on the same practice “page” is on the order of $757
billion. And that’s real money.
I highly recommend a bottom up approach, not top down. That’s how you win docs and influence patients.
Val Jones, M.D., is the President and CEO of Better Health, LLC. Most
recently she was the Senior Medical Director of Revolution Health, a
consumer health portal with over 120 million page views per month in
its network. Prior to her work with Revolution Health, Dr. Jones served
as the founding editor of Clinical Nutrition & Obesity, a
peer-reviewed e-section of the online Medscape medical journal. She currently blogs at Get Better Health, where this post first appeared.