How to Win Docs and Influence Patients

How to Win Docs and Influence Patients


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.

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36 Comments on "How to Win Docs and Influence Patients"


Building on the approaches that show evidence of success will meet far more success than theoretical, centralized planning attempting to force change. In my role promoting physician adoption of EMR’s, I have opportunities to relate to dozens of physicians every week. Most physicians are very interested in better use of information technologies, and most are already demoralized by the controlling entities attempting to force square pegs into round holes.

Mar 2, 2009

What a voice for reason, Dr. Val! This, or something like it, will be necessary to curb costs, and our costly appetites for more health care, but it is not sufficient. Unless and until the incentive structure is changed (can you spell CPT, RBRVS, RUC?) we will continue to get all the procedures our current payment system will pay for.

Mar 2, 2009

Dr. Jones sounds like she has thought this out. Any reform must build from the bottom up. Penalizing hospitals for readmissions is not going to work until the patient is motivated to do right.
We are forever readmitting noncompliant dialysis patients and COPD patients. We are forever seeing the same asthmatics over and over. We are forever seeing the same mental health patients. The patient is a huge part of the costs of care. No one is proposing a carrot and stick for them. The ignorance in the population about basic home care of minor illnesses is culturally ingrained and subsidized by Medicaid.
Are we covering Chiropractic medicine or Podiatry? Are we including Dental care? Are we covering substanced abuse? Are we covering abortions? Let’s use evidence to pay for chiropractors. Are we covering home health?
Any proposal that does not require patient performance and participation will solve nothing. I will not hold my breath waiting. I will stop being concerned about ED waiting times.
What if you don’t want the government in your life? What if you miss your appointment? What if you run out of your medicine? What if you stop taking your insulin because you are tired of it? What if you are cocaine positive at dialysis? What if you cost more than you should? What if you cost more than you are worth? What if you did not vote right? Can we vote? We will leave it to the Central Committee?

Lonnie Fuller MD
Mar 2, 2009

Dr. Jones,
Using a carrot to pay physicians for using a government selected clinical information source is the same for paying physicians for hitting a government selected clinical market such as LDL<100 in diabetics. Since we are more interested in the clinical outcomes, why not pay for them and let physicians decide how to get there? If UpToDate helps more physicians achieve better care, and therefore better reimbursement, UpToDate will earn increased subscriber revenues.

Mar 2, 2009

The carrot approach suggested by Dr Jones seems a good one. It may be wise to re-think its proliferation strategy, however. If this tool truly enjoys “cult” status already, it may prove more effective to capitalize on its cachet by using exclusivity mechanisms and viral marketing techniques, rather than reducing it to commodity status by hard-push selling, discounting, and usage bribes.
Doctors, like most of us, will want something more if it’s believed to be in limited or scarce supply. For example, Google offered new G-Mail accounts during a prolonged “beta” period only by invitation from an existing account-holder. The result: subscriptions soared. Microsoft has gotten better initial exposure of its Windows 7 Operating System through a limited-time download offer than it had gotten in several years of hard-push, paid marketing of its Vista predecessor.
Marketing techniques such as these which offer “membership” in an elite circle will often achieve faster, stickier penetration of new tools than more proletarian methods — at least up to the 50% penetration level.
And what could be more bottoms-up than offering a chance to move up the social ladder to success and recognition…

Mar 2, 2009

I think another initiative should be to make sure physicians and the government understand the benefit a patient centered medical home can play in lowering healthcare costs while at the same time improving health outcomes. It’s proven that if a practice starts implementing steps to become a PCMH, that they see improved outcomes both from the patients standpoint as well as from a financial standpoint.
Why not have a class in every medical school across the country called “Patient Centered Medical Home 101?” If it works…why not start pushing it. If it has been know to provide better health outcomes then why not make it a requirement for practices, etc. Look forward to the feedback.

Mar 2, 2009

There has to be a mixture of carrot and stick strategy….If carrot was al that was going to help then look at the freedom given to financial sector has led to.
There are alot of evidence to support that there are times the issue is simply value related.
To cut the cost and improve the quality, we need to enable doctors to make the right decision, provide them resources, and of course punish them for intentional mistakes or encourage them to leave if they lack competence.
Unless all work together with a sense of sacrifice, healthcare is not going to improve. And yes, even doctors need to make that sacrifice.

Mar 2, 2009

All doctors will do better if they have smarter and healthier patients.

Mar 2, 2009

Couple of points:
1. The study in the International Journal of Medical Informatics is interesting but the authors make it readily clear that they are not sure if the observed outcomes were due to the UpToDate solution, a synergistic effect with other factors, or some other completely different factor(s).
My bet is that it is likely synergistic but is it an important factor worth paying extra money for or just a “nice to have” item that doesn’t fundamentally deliver the “bank for buck.”
2. Why should the federal gov’t directly incentivize a private company in this manner especially given that their are other very viable private competitors out there in the marketplace?
3. To suggest the offering an incentive to use a solution like UpToDate will help to widely curtail the widespread variation in treatments seems like a real stretch. It may have some positive effects on outcomes but I am pretty skeptical that it would put a meaningful dent into practice variations.

Mar 2, 2009

As a doctor how is the Obama’s health care plan going to affect my bottom line. Will I be making more money, less money or the same. Will I work more hours, less hours or the same????????????


If the current reform road maps (i.e. central planning) continue to be followed, it will depend on how well you learn how to game the new system. Doctors that learn how to best game the system will always be able to make more money, if that is their goal. No form of bureaucracy will likely change that.
Ideally, the changes to come will be guided more by patient-centered policy-makers and physicians that deserve their patient’s trust. In such a scenario, the more a physician follows best practice guidelines, the better the patient outcomes and the better the physician incomes.
IMHO, the current road maps appear much more likely to promise more gaming than better health care based on the best evidence. But, it is early in the process.

Mar 2, 2009

More hours, less money. That is pretty clear

Dan Sontheimer, MD, MBA
Mar 2, 2009

Before UpToDate can take this on, it needs to better its evidence criteria. While on its surface it can use the veiled term “evidence-based”, there is a lot of opinion in the content. I know UpToDate, respect some but not all in it. It would be nice to see UpToDate enhanced so that editorial decisions in treatment are easily identified.
The channeling approach mentioned via comparative effectiveness research is intriguing.

Mar 2, 2009

Evidence is a wonderful thing, especially when physicians follow it. But the variation in practice patterns and spending that Dartmouth has documented and that Peter Orszag is worried about won’t go away any time soon on the basis of better use of evidence, for two reasons. One, we don’t have enough eivdence. The number of studies needed is vast, and so is the time its going to take to do them. Two, much of the variation is driven by variation in supply of medical resources — beds, ICU beds, specialists, CT scanners, etc. Physicians unconsciously respond to the supply of such resoources, and to local practice patterns in their towns and in their hospitals. It is going to take a lot more evidence to get them to change those patterns.
While a top down approach is probably not ideal, there are ways to give the highest-spending hosptials incentives to right-size their resources so that physicians practice more conservatively. One is to encourage organized group practices. The Mayo Clinic, The Marshfield Clinic, Geisinger, Group Health, etc etc have done a much better job of matching the resources in which they invest to the patients for whom they are responsible. They also have developed systems of care that are far less chaotic.
Another way to reduce variation, espeically in hospital-centered care, is to invest in primary care. Family practice doctors do a much better job of using evidnece than average, and they have the potential to invest the kind of effort that would increase coordiantion of care, reduce unnecessary hospitalization, and develop a more patient centered system. But we have to pay them to do it.
The idea that more evidence is going to solve our cost and quality problem in the near term I don’t think is realistic. Eventually, yes. Soon enough to avert dramatic and potentially catastrophic spending increases, I doubt it.

Mar 2, 2009

I love UpToDate, I love Val, but giving every doctor a copy of UpToDate and forcing them to use it won’t do much to change practice variation and make us save the $800 odd billion unless there is real dollars attached to those decisions.
I agree with Lonnie Fuller. Let’s pay for the right outcomes and let physicians and others figure out how to get there. And frequently it won’t involved physicians but much cheaper priced labor.
I also realize that “Sam” represents an opinion of many many docs out there, as in “are you just going to pay me less to do more work?” We have to realize that to save the $800 billion in many cases the answer will be yes. And we have to be prepared to have that conversation.