Benchmarking: the key to influencing physicians. (Positively Influencing Physicians).

EVERYONE WHO MANAGES physicians is looking for ways to help them cut costs while maintaining quality of care. But, of course, it isn't easy. Conventional wisdom says physicians always resist attempts to change their practice, And you can double that for surgeons. Physicians are most likely to refuse to comply if they perceive demands for practice changes as dollar driven programs designed merely to save money either for themselves or for their employers.

The problem is, physicians don't relate readily to financial justifications--if that is all they are offered, they will object. Physicians (correctly, in my view) assume case-based clinical patient outcome studies, billing data, or financial projections that are based on summaries from previous years will have a negative effect on how well they serve their patients. And so they resist, earning a bad rap for recalcitrance.

Why benchmarking works

Any approach to clinical practice change based primarily on cost reduction is an effort that can only half-succeed, at best--despite increasing requirements for some type of benchmarking by the Accreditation Association for Ambulatory Health Care (AAAHC), American Medical Accreditation Program (AMAP), and Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Real benchmarking--the process that looks at what physicians are actually doing and compares their performance with others in similar organizations nationwide--is the solution.

Most physicians will accept and adopt scientific medical information that they are convinced can improve their practice. And they'll do it willingly, even enthusiastically, once their competitive sense kicks in. Saving money in this context is just an added benefit.

Start with goad data

I am a surgeon and Medical Director of St. John Surgery Center, St. Clair Shores, Michigan, a large outpatient surgery center with 120 physicians in a wide range of medical disciplines where more than 5,000 procedures are performed annually. We participated in a national benchmarking audit in 1996. The findings were revealing.

In statistical comparisons to similar outpatient surgery centers, we ranked higher than others on costs of supplies and procedure times for some of the most commonly performed surgeries. Our benchmarking rankings indicated that, on average, our physicians were using a higher number of supplies, paying more for them (intraocular lens Implants. for example), and taking longer to complete procedures. Compared to "best performer" surgeons and facilities, our performance was disappointing.

Through no fault of their own, the surgeons didn't have a handle on their practice in these terms. Methods learned long ago hadn't been examined in light of newer technology or techniques- where was the need? As our physicians now confess, before the first benchmarking findings, few had ever considered achieving new levels of efficiency and cost-effectiveness. The benchmarking data demonstrated how different practice techniques used by their colleagues elsewhere lowered costs and shortened procedure times. They became eager to try new methods. They wanted to Improve their practice techniques. They wanted to change.

Benchmarking did not create new management problems, either by entrenching old practice patterns or intensifying turf battles. Rather, management's role has been simplified and transformed by physicians adopting the benchmarking process. Instead of resistance, physicians are grateful for being provided with understandable, relevant information on which to change their practices.

Fee-for-service issues

In the Detroit area, the Big Three automakers are the primary employers and there is little managed care penetration (about 20 percent). This has created a climate in which fee-for-service physicians assumed they could be paid whatever they charged. But at some point, the amount of reimbursement payments will begin to ratchet down. We might not reach the excruciatingly tight levels of some areas (for example, $67 per member per month in San Diego. compared to our $130 per member per month), but obviously, all physicians needed to become more efficient and cost-conscious.

How do physicians know where to begin when you advise them that they need to trim some amount-say, 10 percent or so per case? Without good information, every cost-saving decision could potentially cause dire consequences. In that scenario, some physicians will opt to do nothing, or, at worst, threaten to take their cases elsewhere.

Benchmarking by CPT codes

The kind of benchmarking that will have the greatest impact on physician practices is not based on financial retrospectives of cost centers or cost-per-case numbers. The preferred strategy is based on the Current Procedural Terminology (CPT) codes that physicians use every day to describe their procedures. CPT-based benchmarking looks at the procedures just as physicians do, making it possible to draw direct comparisons between one individual's practice and another's. Physicians trust this process because it speaks their language.

For example, when we looked at our costs for intraocular lens implants compared with other surgery centers, we were surprised at how perceptions (influenced by advertising and marketing), and not scientific studies, were driving decisions. Although no one could say why a $100 lens was not as good as a $400 lens, the belief was that it must be so. We all assume that you get what you pay for. In fact, when we examined the lens specifications there was no appreciable difference--certainly not enough to rule out the less-costly lens--and there were obvious practice implications that made it attractive.

And then, we had evidence from physicians who own small clinics or practice surgeries in their offices. They constantly seek to balance quality and cost. After significant research, these entrepreneurs (who must pay directly for their supplies) were satisfied with the quality of the less expensive supplies. When supply quality and cost were unbundled, many eyes were opened.

Science is key, not savings

This is not a miraculous transformation, although those who have struggled to help physicians change might think so. Benchmarking did not cause our surgeons to have some sentimental change of heart or suddenly infuse them with a new spirit of concern for the institutional financial picture. They were given the scientific tools they needed to make decisions about changing their practice. This had the additional effect of saving the organization a lot of money, but that was not Its primary aim. They were able to reduce supply costs for cataract procedures by more than $85,000 annually while maintaining quality.

The outlook for health care

St. John Surgery Center is in the fourth year of a continuing benchmarking process, one that has also been adopted by the other eight surgical entities that are organizational members of the health system. The physicians are enthusiastic about the improvements that benchmarking has brought because they see them as improving their individual practices.

Detroit's location provides models of supply and demand that can be used to reflect on the future of health care. When automobiles were introduced, they were expensive and few could afford them; they were made in exquisite detail, by hand. But the general public demanded automobiles and the assembly line was developed. There are some lessons to be learned. Its not that physicians should practice medicine in an "assembly-line manner," but medical efficiency is becoming essential.

Advances in medicine and improved life expectancy mean that more people are living longer. There is a need for efficiency and quality control in health care delivery. Physicians are responding by seeing more patients and utilizing the skills of physician assistants and other professionals. While we want to retain as much of the compassion in our work as possible, the future will require that we work smarter and harder to meet the needs.

And this is where benchmarking is essential. When we looked at the results of our second benchmarking study, we could see how much progress had been made. Physicians adopted new techniques, using fewer or less costly supplies, and are achieving a continuing high level of quality. They give every indication of maintaining that process. The surgical staff is performing more efficiently, the educational value for every level of the organization has been Impressive, and the savings are substantial.

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RELATED ARTICLE: BENCHMARKING USES CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES

Current Procedural Terminology (CPT) codes, designed more than 30 years ago by the American Medical Association to provide a uniform language to identify procedures and medical services performed by physicians, have more than fulfilled their original purpose. CPT listings are updated annually to reflect changes in technology and practice. As a system of terminology, CPT codes are the most widely accepted nomenclature for reporting physician procedures and services as the basis for fees.

Other systems of nomenclature, such as ICD-9 or DRG codes, are less well-known or understood by physicians. Crosswalks exist between the codes but their best use is dictated by their application-ICD-9 and DRG codes are embedded in hospital inpatient payment systems (although CPT codes are used to bill insurance carriers for outpatients). Hospitals may naturally prefer to use inpatient payment codes as fiscal denominators, but physicians often find DRGs too general as they lump many procedures together, while the 20,000+ ICD-9 codes are viewed as too specific (e.g., the same procedure on the right or left thumb has two different codes).

With the shift of surgery to outpatient classifications, CPT codes are increasingly efficient. Comparisons at the CPT level afford physicians common reference points for evaluating recommendations and findings; they know the specific practice and processes described. Cost-center data or DRG data, unlike CPT coding, is too far removed from the physicians' point of reference to be useful. The information is not in a format that physicians can assimilate. They do not deal with averages beyond recognition, but with specific patients or procedures. Most physicians do not care to learn accounting language; they have enough to learn in their own practice. The hospital should use CPT codes to "translate" information into their terms if it expects to see changes in practice that can lower costs. Practical information, when it is presented at the physicians' level and in context, will lead to behavioral changes.

Effective benchmarking uses the clinical model.

Because their medical practices are data-driven, it is not surprising that most physicians will see me parallels and accept the implications of benchmarking more quickly even than non-clinical managers. An effective process for health care providers is designed on the clinical model used by physicians to assess their patients. Each step of clinical assessment is comparable the organizational benchmarking audit process.

Just as in a clinical assessment, each step in a benchmarking audit is designed to achieve optimum results.

Clinical Assessment Process

Assess

Diagnose

Intervene

Evaluate

Benchmarking Audit Process Patient Problem

1. Departmental or procedural problem

2. Gather key data

3. Analyze best alternatives

4. Adopt best practices

5. Monitor improvement

Here's a typical scenario:

* Select a procedure

* Solicit participants for comparison

* Develop a cause-effect diagram for the procedure

* Develop key measurement criteria

* Develop questions to be answered

* Develop survey tool to gather data to answer key questions

* Pilot test survey tool with other participants; revise as necessary

Step 1: Department or procedural problem

To achieve staff buy-in, choose a high-volume or high-risk procedure that could be improved. Selecting a procedure the staff believes is done well will either open their eyes or make them search for flaws in the study, so be prepared with "bullet-proof" data. Don't lose focus and don't attempt to include too much in the study.

Step 2: Gather key data

1. Collect data according to CPT codes and any additional criteria

2. Validate data collection among participants by confirming definitions

3. Enable active oversight of data collection by physicians and nurses

Develop ownership by involving staff in data collection. Staff should know sampling techniques, analysis methodology, and reporting techniques. To be successful, the process must make sense to end-users.

Step 3: Analyze best alternatives

1. Validate the data collected; identify and review outlier data

2. Interview best performers; review their data collection definitions and techniques

3. Determine positive variance in practice by site visits to best performers

Once better performers are identified, secondary research (interviews or site visits by physicians) will create a better understanding of the positive variance in practice that drives the numbers.

Step 4: Adopt best practices

1. Implement alternative practices in a brief trial to enhance awareness and buy-in

2. Communicate about implementation

Physicians tend to be more comfortable adopting alternative practices than nurses or managers. Unlike some managers who get stuck in analysis paralysis, physicians will study and use newly found best practice techniques. All best practices may not be suited to all organizations, but they can still improve outcomes by using a variation of the best performer techniques.

Step 5: Monitor improvement

1. Celebrate successful implementation

2. Conduct a follow-up study in six months to maintain improvements

Once alternative techniques and best practices are implemented, communication, recognition, and reinforcement must occur. Schedule a formal review in six months to confirm that old practices are not creeping back.

Daniel Dj. Megler, MD, is Medical Director of St. John Surgery Center in St. Clair Shores, Michigan. and an otolaryngologist with a special interest in head and neck oncology. He is a prolific author and speaks frequently to professional societies and business coalitions on health care topics. He can be reached via email at [e-mail].

Girard F. Senn, MS, RN, CNAA, is Principal and Executive Director of Clinical Benchmarking, LLC, in Glen Ellyn, Illinois (website: www.Clinmarking.com). He has 15 years of health care experience in senior management and consulting roles, both in hospitals and in national consulting firms. He can be reached via email at [e-mail].