Outpatient critical pathways: five advantages for physicians who act now.

Simply put, critical pathways apply the principles of total quality management to clinical care. Aiming to improve quality and lower costs by reducing variation in the process of providing health care, a critical pathway defines the process, time-line, and responsibility associated with meeting a patient's clinical needs. For inpatients, the critical pathway covers all expectations from pre-admission (for elective admissions) to postdischarge. For outpatients, an effective pathway might run from presentation and diagnosis to cure, covering all expectations across the entire continuum of care.

One health maintenance organization, with 15 different clinics and 50 primary care practitioners, noticed a significant and troublesome variation in the clinical management of 40-year-old men with lower back pain. Although the men all presented with similar etiologies and severities of illness, the prescribed treatments ran the gamut: Valium[R] and Flexeril[R]; non-steroidal anti-inflammatory medication; physical therapy; a tear-off sheet of exercises to do at home; a complete series of spinal x-rays; a myelogram; a CT scan; an MRI; and referrals to orthopedic surgeons, neurosurgeons, and chiropractors. What's wrong with this picture? Isn't there a demonstrated best outpatient management protocol for lower back pain?

The answer is yes, depending on the patient's presentation. And no longer can our health care system tolerate the financial and human costs of such wild variations in the treatment of lower back pain or any other illness. Capitated health plans are embracing critical pathways as a superior way to manage costs and ensure high-quality outcomes for inpatients and outpatients alike. Surely physicians, too, will warm up to the idea as they learn more about critical pathways and see more advantages for their own practices.

There are five excellent reasons why doctors should start learning about, creating, and implementing outpatient critical pathways:

1. Capitated health plans are eagerly seeking physicians who can demonstrate reasonable costs and high-quality outcomes

Managed care plans use last year's data to choose physicians for next year's provider panels. In particular, plan managers scrutinize outpatient charges per case and outcome quality indicators by physician. Physicians who intend to survive under capitation should waste no time in creating and reviewing their own data and establishing a consensus regarding the best care management protocols for various outpatient clinical presentations. Some physicians will be left out of plans simply because they don't know what they don't know. And those depending on the "any willing provider" laws being passed in some states may be in store for a big disappointment. Even under such laws, health care plans will rarely assign their members to a physician who can't demonstrate value. Today's astute providers are showing their willingness to meet cost and quality expectations and to fulfill all plan requirements, letter and spirit.

2. Outpatient critical pathways will give your practice a head start on insurer-mandated pathways

You might as well learn about, create, and implement outpatient critical pathways now, and of your own free will. Before long, pathways and pathway-building skills will come in handy. Some insurers are already mandating compliance with their own outpatient critical pathways. Blue Cross/Blue Shield of Illinois has created no fewer than 14 of them, several designed for the outpatient management of cancer patients in the 18 months following the removal of the initial primary tumor. These pathways include cancers of the lung, breast, and colon and describe how often postoperative patients should be seen (usually every 3 months) and what tests should be performed at those visits (usually a thorough examination, assuming there is no recurrence of the primary cancer). The advantages of such protocols are manifold. First and foremost, insistence on frequent monitoring offers cancer patients a strong safety net. With vigilant follow-up care, physicians can usually catch the cancer before it recurs in a state of metastasis, and such early detection and intervention affords plan members the best chance for longer life and improved well-being. In strictly financial terms, the increased efficiency of care management according to critical pathways promises to reduce Blue Cross/Blue Shield's overall expenditures for outpatient cancer treatment.

3. Critical pathways work

Physicians have long adhered to critical pathways of sorts and have gladly volunteered to uphold certain clinical standards for the public good. Why do we have only one pediatric immunization schedule for every person on the planet? Because it works. Through solid clinical research, the world health community has decided that there is most assuredly a demonstrated best immunization methodology that affords all patients high-quality protection against disease and that can be delivered in a cost-effective manner. The accepted schedule for oral polio vaccine, for example, is one dose the first two months of life. A two-month-old baby will be just as effectively protected against polio by one dose as he or she will be by five doses. Let the skeptics say, "We need to protect the Art of Medicine" or "I don't like `cookbook' medicine" or "This is the way I've always done things"--no such excuses can justify giving five oral polio vaccines in the first two months.

Other critical pathways are not nearly as well worn or well accepted as the pediatric immunization schedule, and there are always exceptions and acceptable variances. But what has worked so effectively in the realm of public health is also working today in private practice.

4. Outpatient critical pathways improve patient satisfaction and reduce medicolegal risk

Patients want to know the care plan, and they want physicians to explain the recommended course of action in no uncertain terms. The satisfied patient is fully informed and knows precisely what to expect. Even physicians who already do an excellent job of communicating their findings, assessments, and treatment plans will benefit from the structured discipline of critical pathways. Simply distributing copies of critical pathways has been shown to improve patient and family satisfaction. Furthermore, hospital systems that have implemented critical pathways have witnessed significant reductions in the number of malpractice lawsuits filed against their institutions and clinicians. Some states--Maine, for one--have even, passed laws that protect physicians who follow critical pathways or who document their reasons for deviating from standard protocol. Legal scholars and judges likewise recognize critical pathways as representing the acceptable local standard of care. As inpatient and outpatient critical pathways become commonplace, they will provide more and more medicolegal protection for physicians wise enough to follow them.

5. Outpatient critical pathways can boost your take-home income

Have I gotten your attention now? When your practice starts reaping the demonstrable benefits of outpatient critical pathways, payers will take note of your improved utilization and high-quality profile and will more likely include you on their panels of providers. That means a solid patient base and a steady practice volume. And, under future capitation arrangements, your ability to utilize resources more cost-effectively and to provide high-quality care will translate directly into higher net income.

All in all, these five advantages should provide ample encouragement for physicians who have been reluctant to explore this promising new approach to low-cost, high-quality medicine. As critical pathways wind their way into outpatient settings, they will become even more essential to your practice. Some will sit by and wait for insurer mandates. But the everyday reality is already upon us. Now, not later, is the time to create, implement, and follow your own outpatient critical pathways.

Charles D. Musfeldt, MD, MBA, is a health care consultant in Naperville, Ill. He can be reached at 109 W. Jefferson, Naperville, Ill. 60540, 708/637-1057, FAX [phone], e-mail at [e-mail].