Comparative Effectiveness Research (CER) is suddenly a hot topic at all the health care conferences. How come? Everybody agrees that we have to decrease per-capita cost and increase quality. Why? Government programs like Medicare and Medicaid foot more than 50% of our nation’s health bill, and if everything stays the same these programs will go belly up (bankrupt) in 8 years. Big problem.
Health and Human Services (HHS) has defined comparative effectiveness research as conducting and synthesizing research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in “real world” settings. In other words, CER is figuring out what treatments, tests, and drugs work and which ones don’t work.
John E. Wennberg spent a whole career at Dartmouth studying American medicine, and he comes to the startling conclusion that 60% of Medicare is spent on supply sensitive care (physician visits, consultations, imaging exams, and hospital and ICU admissions) and 25% on preference sensitive care (PSA tests, mammography, and elective surgery). Although we assume that this care is based on solid scientific evidence, Wennberg states that “medical science is virtually silent on such matters” as how often to see a patient, what test to order, and whether to admit a patient to the hospital or ICU. Some evidence based medicine experts state that only about 20% of what physicians do is based on sound science.
“Great companies have high cultures of accountability, it comes with this culture of criticism I was talking about before, and I think our culture is strong on that.” – Steve Ballmer
“I am responsible. Although I may not be able to prevent the worst from happening, I am responsible for my attitude toward the inevitable misfortunes that darken life. Bad things do happen; how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss, or I can choose to rise from the pain and treasure the most precious gift I have – life itself.” – Walter Anderson
“When it comes to privacy and accountability, people always demand the former for themselves and the latter for everyone else.” – David Brin
Accountable care organizations (ACOs) are all the rage as the perfect tool to achieve our most important goal in present day American health care: decreasing per-capita cost and increasing quality at the same time. Just this week I am presenting on ACOs at a law firm conference co-sponsored by two state hospital associations and the MGMA in Minneapolis and at a hospital system board retreat in Pennsylvania. Everybody wants to know how to implement ACOs.
An essential ingredient in ACOs is accountability, and yet human beings are not always comfortable with being held accountable. The two blog posts I wrote on physician report cards generated a lot of comments both in favor and opposed to personal accountability. And yet we know that hospitals and physicians are going to have to change the way they utilize medical resources if we are to indeed decrease per-capita cost and increase quality. Hospitals account for 40% of the rise in health care costs. Physicians account for only 20% of total health care expenditures, but when they treat patients they control the use of hospitals, drugs, medical devices, and laboratory tests.
If we are to control health care costs, hospital admissions will have to go down and physicians will have to order fewer and less expensive tests and treatments than they do today.
In Quality Measures and the Individual Physician, Danielle Ofri, MD, PhD, questions the usefulness of feedback report cards for individual providers. She states, “Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my institution’s targets.” (http://danielleofri.com/?p=1169)
It would be better for Dr. Ofri’s patients if these numbers were higher. I think even Dr. Ofri would agree with that assessment. And yet Dr. Ofri’s response to these low scores is that “the overwhelming majority of health care workers are in the profession to help patients and doing a decent job.” And more upsetting is Dr. Ofri’s conclusion where “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.” (http://danielleofri.com/?p=1169)
Not long ago I was lucky to be invited to a New England Healthcare Institute discussion entitled “From Evidence to Practice: Making Comparative Effectiveness Research Findings Work for Providers and Patients “ in Washington, DC.
How to disseminate and implement Comparative Effectiveness Research (CER) so that patient care is really improved was the first topic tackled by the expert panel and the moderator, Clifford Goodman of The Lewin Group.
The target audiences for CER findings include: patients, disabled patients, providers, policy makers, health plans, medical device companies, pharmaceutical companies, hospital administrators, academic researchers, community physicians, professional societies, and regulators.
Michael McGinnis, MD, of the Institute of Medicine, offered clusters as a way to organize these different targets: Cluster 1 (patients, providers, policy makers), Cluster 2 (control levers like payers, purchasers, system managers, professional societies, regulators) and Cluster 3 (researchers and those concerned with methodology).
Seth Frazier, Vice President of Transformation at Geisinger, was the first of many to point out the gap between the academic literature of CER and what patients and providers need at the point of care. He noted that providers need actionable recommendations that can be integrated into the flow of the clinic and hospital and that much of the evidence-based medicine product is not usable in this practical way. This observation reminded me of the gap between the public and the health care experts that Drew Altman of the Kaiser Family Foundation documented so effectively and the Kristen Carmen Health Affairs survey that said patients regard evidence-based medicine as a barrier to what they want.
When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters. I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool. As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes. I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom. Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.
Mistakes and errors are on my mind because I just finished reading some extraordinary works.
The task of health care reform in 21st century America is to decrease per-capita cost of care and to increase the quality of care delivered to patients. It’s complicated. A famous Rand study concluded that Americans only receive 55% of the care that science dictates. Patients intuitively believe that more health care is always beneficial. Medicare reformers would like to do comparative effectiveness research so that CMS and private insurers could wind up paying only for therapy that actually works. Some estimate that 30% of all care delivered in the United States is waste. What some call waste, others label revenue, and Atul Gawande becomes famous for identifying waste/revenue in McAllen, Texas (http://bit.ly/ENlli).
Neuroscience tells us that the smartest human can only keep track of seven variables at one time, and physicians tell us that diagnosis and treatment of a complicated patient can involve as many as 100 such variables. Computers are good at cataloging, organizing, and retrieving information, but physicians are not yet routinely utilizing them at the point of care. Computers are also good at allowing us to analyze large data sets and learn from experience. Patients yearn for the warmth and caring of a doctor who really knows and cares about them. Behavioral economics pioneered by Amos Tversky and Daniel Kahneman taught us that human brains are designed with inherent biases that make us less than rational decision-makers. We now know that human physicians and patients suffer from biases such as Pygmalion complex, confirmation bias, focusing illusion, incorrectly weighing initial numbers, and being more impressed with single cases than conclusions based on large data sets (http://bit.ly/49q4Uy).Continue reading…