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 replies »

  1. I will right away snatch your rss as I can not find your e-mail subscription link or newsletter service. Do you have any? Kindly let me recognise in order that I could subscribe. Thanks.

  2. Oh, No special treament for the Rush Limbaugh who has put a Free advertising plug in for the Industry. Tort Reform is not the issue as only 1 to 5 %percent of lawsuites proceed with any rewards. These are the most serious Cases of Medical Error that end in a lifetime of infirmity, Disability and Death. Tort Cases are the ONLY means of accountability! Otherwise, the patient would bare the insurmountable costs of Medical Error.
    The problem is,neither the doctors or the institutions want to be Held accountable for anything that may happens. If it be Medical Error or Hospital Acquired Staph Infections. They Contend that the patient is privledged for the knowledge and skill of the Doctor and the technology of the institution. If the results end to be; the amputation of all limbs from Preventable Staph Infections or simply operating on the wrong body part. No one is accountable . You should just be happy that you are alive and have not severed a critical organ. So what, if you cannot walk ,work ,or feed and cloth yourself! Doctors and Institutions do not accept any responsibility.
    Tort reform is not the answer. Accountability and responsibility for errors would lend toward fewer extremes and legal actions. Consumers are left out of the debate simply because the contracts are between Insurance and the Provider.

  3. Its Amazing that Doctors are more concerned about Corporate Compliance boards than doing right by patients?How Fasinating to realize that the patients are not the Focus of their Concern but rather Corporate Boards and Health Insurance.
    How niave it is for the patient to believe that doctors are in it to save lives.They don’t have the common sense to understand that Health Care Professions are part of a Business profoilo.Private corporations will sacrifice people to survive and so does Health Care.
    We have taken Health Care from a comprehensive measured Care. To itiemized list of products and services that fails to serve the best interests of patient: Managed Care. The system is organized to maximize patient profitability and limited access.Our system of Professional speciality leaves such larges cracks for patients to fall through. That the no Child Left behind Act was a controlled clinical study,in comparison to Todays Health Caring.

  4. Healthcare Information and Management Systems Society is in “Dire Straights”
    CEO, H. Stephen Lieber recently announced to staff: “I am not planning to layoff anyone, but we are in Dire Starights. We need to apply for government grants that are offered as part of the $20 billion HIT plan”.
    Employees questioned how Healthcare Information and Management Systems Society can be in “dire straights” if Healthcare Information and Management Systems Society had a $1 million surplus the year before, when staff were asked for ideas on “how to spend a $1 million”.
    Lieber plans to continue with the FY09 Healthcare Information and Management Systems Society Staff Incentive Plan. “The incentive plan is distributed based on a conpensation pool approved by the BOD in the annual budget. Each employee’s pro rata share amount is determined by this calculation: (employee’s compensation/total compensation pool). The employee’s eligible incentive amount is then calculated: number of shares x share unit value.” Staff are unaware of “shares” offered by Healthcare Information and Management Systems Society for bonus compensation and any “shares” registered with the SEC.
    Lieber does not plan to layoff staff, but staff are being fired at an alarming rate. Below is an accounting of the current state of affairs at Healthcare Information and Management Systems Society within the last month.
    1. Three accounting staff fired. Two were minorities on staff for years. The Finance Department was already overworked and now they are understaffed.
    2. Sr. Director of IHE (Integrating the Healthcare Enterprise) resigned. The position was high profile, with key emphasis on implementing and integrating standards for interoperability. The employee was the Chair of Interoperability Showcase for 2005 and 2006. The position was never advanced at Healthcare Information and Management Systems Society, and patient safety, privacy standards and HIPAA are not in place. Employees are not surprised, considering the HIPAA and civil rights violations filed by employees against the VP of Communications to several state and federal agencies. Investigations are under way.
    3. Director of Corporate Sales resigned due to a conflict with the Executive Director (ED) of the North American division. The employee complained the ED has no clinical or technical background in the industry to guide staff.
    4. Sr. Manager of Public Policy Communications in Virginia recently resigned.
    5. Healthcare Information and Management Systems Society as taken a loss with international conferences and educational seminars. The current VP of Education has no educational background or degree in education, and educational topics are proposed by Healthcare Information and Management Systems Society vendor trade association, EHRA. Healthcare Information and Management Systems Society offers conferences in Asia, Europe and Middle East, despite less than 12% adoption rate in the U.S. Healthcare Information and Management Systems Societynow offers publications translated in Spanish, so South America is rumored to be a future conference site.
    6. Lieber is aware of the competition and conferences offered that advance and lead the adoption of health information technology. Lieber is optimisticHealthcare Information and Management Systems Society will receive a big chunk of the government giveaway.
    7. More dogs hired: two corporate lawyers now on staff full time, with outside counsel retained, as legal problems regarding human rights issues escalate.
    8. There is no functioning PR or HR department within Healthcare Information and Management Systems Society. Everything goes through and is approved by corporate counsel.
    9. Healthcare Information and Management Systems Society denied surveillance cameras were in place when CPD interviewed corporate counsel regarding senior management violence inflicted on an employee, all caught on overhead camera while sitting at a desk. Healthcare Information and Management Systems Society does not remember the same cameras caught a thief entering the Healthcare Information and Management Systems Society premises in 2005. Photos from the surveillance cameras were posted throughout Healthcare Information and Management Systems Society.
    10. Healthcare Information and Management Systems Society is actively spying on employees who engage in electronic chat conversations, saving their Instant Messages. A Service Desk Analyst was recently fired for informing staff of new internal procedures.
    11. Healthcare Information and Management Systems Society is offering in-house sexual harrassment seminars due to a high level executive male employee harassing a female employee. The harasser is still employed and the victim was forced out. Employees have requested bullying seminars instead.
    12. Upper management has employed a smear campaign against all employees who have left Healthcare Information and Management Systems Society and who have filed complaints for civil rights violations and HIPAA, to try to discredit testimony supplied to several state and federal agencies for ongoing investigations.
    13. Worker’s compensation cases are blocked by Healthcare Information and Management Systems Society and its insurance agent against minorities. Healthcare Information and Management Systems Society is trying to dismiss all agency complaints filed against their organization because it will affect their ability to apply for government grants.
    14. Gossiping and back stabbing at the executive level toward staff continues and has staff worried about their jobs, wondering who will be next on the “chopping block.” The future of Healthcare Information and Management Systems Society is questionable under its current leadership.
    A. Count Ant

  5. We should neither encourage nor fund “thousands of unemployed single Moms”. It takes two parents to raise a child, not a village.
    The people in this country need to love and cherish freedom from governmenmt oppression and tyranny above all other civic and social things.
    Evidence in medicine is great. But somethimes a doctor has a hunch that either pays off or doesn’t. If is were easy to be a doctor, a caveman could do it with a computer, protocols and algorithms. So why don’t they? When all the evidence is in and the results are bad, the computer doesn’t hold your hand or hold you or console your grieving family or even remember you. And it doesn’t learn anything for the next time. It can’t see you. It can’t see the looks on family members faces. It won’t be fed the information that is learned from, “can I talk to you outside, doc? I don’t want him/her to know I talked with you.”
    Hospital readmission rates are more about the population they serve than about the hospital itself. Punish hospitals for higher readmission rates and they will go out of the nephrology business, the oncology business and the pulmonary disease business.
    Each doctor is a cottage industry doing custom piecework. Hardly big business. Most big business is private. If healthcare were a private business, everyone could afford basic care. Government took the $12 office visit of 1980 and made it the $100 visit of today. Catastrphic care could be funded through a real insurance risk pool. Would you like to fly on a Boeing 787 or an Obama 2009?

  6. HD,
    One empathizes. I agree that anyone with the slightest of basic healthcare knowledge can pick up a CPT code book and order tests; however they cannot analyze those tests and provide a treatment plan.
    About the little girl, I do believe people young and old should be allowed to die with dignity and respect.
    With that I have but a few questions for you:
    Have you ever held a little dyeing girl? Have you ever had a family member plagued with a chronic illness? Have you ever felt, tasted the pain, the agony the anger, the hurt those families of them shed? When you have a human being die while you watch and see the sheer magnitude and profound effect it has on the ones they leave behind? Have you ever had to see a father beg you to do something when there is nothing that could be done? A wife pleading to God to take her life and not her husbands or her child’s? Your Apathy would tell me you have not. Or perhaps you have seen it one too many times. Never the less your callousness leaves me with such distain and pity for you.
    I want you to think of what you LOVE and cherish the most in life (if anything) and ask yourself if it was going to be taken away, what would you do for just one more day, one more hour, one more minute. Then reread your last post. I have been in healthcare since I was 18 years old I am now 35. I have seen the good, the bad and the ugly. I have worked in just about every discipline including oncology. I can tell you from EXPERIENCE that when you see a young lil girl smiling knowing she won’t see her next birthday it makes you realize real quick what’s important. The courage she has to live one more day even though the pain is more than you or I could fathom.
    No one is reinventing the wheel for medicine. Yes like I said with any profession they are bad apples the bring shame on the profession, but that doesn’t mean its all bad. We had a president who brought more than shame to the highest office the US has but we still need a president.
    One last thing in medicine you never stop learning and there is always new treatments coming up every day.
    I fault you not for your ignorance or you lack of compassion, as I said I pity you…….. You must live a very sad existence…
    A lilttle food for thought if your ineptness will permit it.
    You must not lose faith in humanity. Humanity is an ocean; if a few drops of the ocean are dirty, the ocean does not become dirty.
    Mohandas Gandhi

  7. You make some very good points, but you are missing the main thrust of Nationalized Healthcare. This is what the experts who are designing policy know:
    1) Medicine is actually very simple and easy – doctors just use the “8-12 years of post-college education excuse” as a way to corner the market on a lucrative career. The field should be open to anyone who feels doctorish.
    2) All doctors can easily be replaced by PA’s and NP’s or techs who just pull up an ICD-10 code and look to the 3rd party payer to see what treatment/medication is authorized. That’s all you’re going to get anyway.
    2) Everything about the human body and every possible medical treatment is already known, and does not change. It is un-american to suggest otherwise. Let’s end the wasteful spending on these fancy new drugs and procedures.
    3) It is silly to have a “medical expert” re-invent the wheel every time a 12 year old girl shows up with fatigue, weight loss and a generalized itchy skin eruption. Sure, it could be atopic dermatitis, but if it is Hodgkin’s disease, won’t that will reveal itself when the she dies in a year or two? And won’t it be better for the “bottom line” if she dies sooner rather than after years of futile treatment?
    4) People die. People are being selfish, and short-sighted to think they deserve help delaying death. The public must be willing to give up this immature notion for the greater good.

  8. A kiosk? What you have to be joking! First and foremost no computer will ever take the place of direct patient care. (Lord knows we have enough med mal when they see a live DR.)
    I have worked in several ER’s in various states and I know all too well the “frequent flyers” that “abuse” the system.
    I do think that evidence based practice is a KEY component of healthcare reform coupled with managed care (case management and medical management)
    I can tell you from an ER nurse’s prospective that you know the Dr.’s that are going to test a patient with an ingrown toe nail as if they were in multi system organ failure and those who don’t treat at all because of whatever reason.
    Bottom line it is up to everyone to implement and except change.
    We all must take pride in what we do, hold ourselves accountable for our actions, and have the highest of standards.
    From a medical prospective it’s terrible to have to work alongside MD’s who don’t have a clue, but it’s an honor to work with a competent compassionate MD no matter what discipline you’re in.
    From a legal prospective MED MAL is just sickening. If you are a provider, and you don’t know what you’re doing or how to do something get off your horse and get help or pay the consequences of being ignorant.
    Yes patients should be held somewhat responsible for their own healthcare and noncompliance should be reportable and in some form accountability needs to exist.
    However, in case you have missed the bus healthcare providers are public servants.
    I think each Dr. Nurse, institution, insurance company etc should be monitored and controlled like any other business. You have customers if you do right or well you get repeat business, if you do wrong or have poor customer satisfaction then no more business. I realize that demographics plays a role in this, but healthcare is BIG BUSINESS and if it was held to the same standards as other business’s it would have been out of business long ago. (LOL)
    I think that good (experienced) DR.’s are well educated and do use evidence based practice. They don’t need anyone to tell them what to do and how to treat their patients. Its the john dumbs that think they know better than everyone, and will take full advantage of any situation to turn a buck. I refuse to believe that the majority of MD.’s are fraudulant or ignorant but the ones that are need to be identified and booted out of such a noble profession.!!

  9. Select Collect: A novel and cost-effective approach for patient collection. The client designs their own collection process by selecting the activities that they would like to be performed on their accounts. Interestingly, these are most of the same techniques that may have been used on their accounts in the past by a conventional collection agency. However, in this program, the client retains 100% of the money collected and is only billed for the activities selected.

  10. A Top Down Approach is the Answer
    rbar is right: A sick person should be able to enter their symptoms into a waiting room kiosk, while at the same time, their vital statistics are taken by the machine. A simple Evidence Based formula could be used to treat the patient with printed messages, such as:
    1) “You have a cold. Go home and have some soup.”
    2) “You have a sinus infection. Take your printed prescription for the cheap, outdated, antibiotic to the Pharmacy window.”
    3) “You have had a severe head injury and cerebrospinal fluid is leaking out your nose. You may wish to see a doctor, but since they designed such a nice top-down formulaic system, there really wasn’t much need for them anymore, and there aren’t any left so keep wishing.”

  11. Can quality in healthcare and equality of outcome co-exist? Will electronic records or a “medical home” make a difference? Who cares? Either way it means billions of dollars to the businesses that win these government contracts. That’s a win for the economy! That’s a win for America!
    The discredited study promulgated by Dr. Jones can still be used to prop up the argument for centralized control of medicine. Studies show that no matter how wildly inaccurate the study, if the results are quoted in the media often enough they become TRUE!

  12. An honest discussion of American Medicine is not complete without mentioning some responsibility on the patient’s side of the equation.
    A simple solution, and one that has a great deal of appeal to third party payers and cost containment experts in Medicare, is to deny medical care to those who display unhealthy behaviors such as smoking, drinking, eating fast food, maintaining an abnormal Body Mass Index, failing to excercise, or those who have a genetic predisposition towards certain disorders.
    Insurers and hospitals are also interested in denying care for those who are injured while engaging in risky activities such as driving while intoxicated, working with tools without proper training, riding a bicycle, or playing sports.
    The other obvious solution that Ms Maier has repeatedly hinted at and which is being given serious consideration by healthcare cognizetti, is to stop spending 90% of our healthcare dollars in the last weeks of life. This is especially egregious among the elderly population who as a demographic, hold more wealth than any other segment of society, yet are asked to pay very few taxes because they no longer earn wages. This is the elephant in the room. The net drain on our economy by the elderly is crushing this country -and Baby Boomers are just beginning to hit retirement age.
    Any reasonable and honest solution to American healthcare must consider withdrawing all benefits for the elderly once they cannot care for themselves. At some point all Americans must agree that it is outrageously selfish for a person with only a few years of feeble inactivity remaining, to demand the maximum effort from the medical community to sustain that life. There is no return on this investment.
    If instead, we were to liquidate the wealth of every physically feeble, non-productive person over the age of 68, it would free sufficient funds to pay for the healthcare of the over 50% of Americans who are so impoverished that they don’t pay any income tax. It would help sustain the healthcare of the millions of Americans who, through no fault of their own, are here illegally. It would pay for the hundreds of thousands of young, unemployed single mothers so that American can rebuild the foundation of its economic might, which has always been unemployed, single persons with children.
    We should each urge the new administration to move forward with these carefully considered, common-sense measures, as a first step to a Healthier Tomorrow.

  13. Right Ms. Burton,
    That’s why the same dialysis patients come in volume overloaded. That’s why the same asthmatics come in out of their medicine. That’s why the same diabetics come in not taking their insulin. That’s why the came chronic pain patients come in seeking narcotics. That is why the same heart patients and COPD patients continue to smoke. And I am an ED doc and my patients know they can call me and I also run a doc-in the-box separate from teh ED. I know many of these patients. ED medicine in a small town is not anonymous.
    There is something that purpetuates unfortunate but bad behaviors, despite health consequences that no amount of one on one counseling over 27 years has been able to change. I still try. And I am board certified and I have been in the same ED for 27 years. And I receive one out of every three dollars billed. Please cover everyone so that can be one of every dollar billed, because I know I earn it! Come back if something is not right. I’ll be right here.

  14. Patient ignorance culturally ingrained????
    Did you for one minute think that maybe, just maybe, the physician, the nurse, or the discharge planner didn’t do their job in explaining to the patient what they need to do at home? Do you have them repeat to you the instructions you gave them? Do you tell the patient that they or a family member are free to call you if there are any questions?
    Emergency room docs are the very worse at this because they think if a patient comes back he/she will probably be seen by another doc-in-a-box!
    I hope that President Obama holds you to even higher standards! Do you ever ask yourself why you became a physician? Was it because you really cared about people and you wanted to make a difference? Was it because you could make a lot of money, put yourself on a pedastal and act like you are above everyone else, especially your patients?
    I think physicians need to be paid well. However, I think you have to earn that payment!
    Perhaps M D Hell, you need additional training. I think so.

  15. “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.”
    As I have stated before, health care providers will have to become civil servants just like police and fire if you expect to save money. This removes all of the incentives to over treat or over fear legal ramifications.
    It is a workable solution for the next generation of physicians who have not overly invested in their career and are more capable of handling the change. It will have to be done correctly with similar retirements (yes you keep your final salary for life), time-off and other paid benefits that these other civil servants have. This really is not a bad deal. I’d be glad to work for $185,000, have paid vacation, use of a public vehicle and retire after 20 years with the same salary adjusted for inflation. You don’t have to worry about gambling your benefits in a 401K on Wall Street. Most of us are still small businessmen battling the same battle as other businesses. There are significant risks and therefore significant rewards for those that play the game successfully.
    The conversation has begun.

  16. I second rbar. The family docs with which I had experience (with one exception) were the least evidence-aware of the physicians with which I dealt.
    If we are going to emphasize their role, then their training will have to change, or there will be many missed diagnoses out there. I know this is a generalization and probably not represented by most family docs who read this blog – but it’s the ones who don’t care who do NOT read this blog.

  17. Shannon,
    I agree with most of what you write, but
    “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” etc.
    I am a nonprocedural specialist and most PCPs in my area do not practice EBM where it matters – prescribing ABx left and right and scans for no good reason (mostly due to patient preference and defensive medicine, I’d guess).
    Which brings me to my point re. EBM: we physicians have to acknowledge the cost explosion desaster and simply hammer some points home, starting in med. school: no ABx for common cold or headaches, no neuroimaging for typical episodic headaches, specialist referral before scanning and tort reform, for that the specialists can use their judgment what is wothwhile doing and what not (currently, it seems that a lot of focs simply do everything). In other words: on some common situations, we need a simple top-down approach.

  18. Two comments
    I’m tired of some Doctors on this blog complaining about reduced incomes.It’s long overdue or at the very least shifting dollars from super-paid greedy specialists who overtreat and over-procedurize to primary care docs on the front lines.
    Also “Every American citizen deserves a dignified pain-free death”-ral. Profiteering off the dying is the moral lowpoint in a for profit model of US Health Care. It is truly shameful.
    Dr. Rick Lippin

  19. Great post and a nice break from all of the usual garbage about the Obama budget. I’m going to mention UpToDate to the docs in my group to see what they think.
    Can everyone please click on Dr. Val’s link to CBO’s top three causes of rising healthcare costs? Most of the things we talk about on THCG ad nauseum do nothing to address the top two. It leads me to believe that most are not willing to contribute to reform. They are more interested in talking about it and waiting for Obama to “handle” it.

  20. Shannon – I know that one of the reasons the NIH funding was raised by $10B was the last few years of static funding but another key reason was the number of grant proposals were given high scores in recent years yet did not receive funding & decrease in funding for new PhD researchers.
    Is the same for AHRQ?

  21. 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.

  22. 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.

  23. 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.

  24. 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.

  25. 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????????????

  26. 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.

  27. 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.

  28. Hello,
    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.

  29. 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…

  30. 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.

  31. 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?

  32. 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.

  33. Amen!
    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.

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