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Effectiveness of medical treatment under scrutiny.

After little more than a year, public and private sector initiatives to study the effectiveness of medical treatments have become the focal point of efforts to control utilization of health services.

It was just last summer that the Health Care Financing Administration unveiled its so-called effectiveness initiative: a coordinated new attempt to define "what works" in medicine. The research seeks to compare the best methods for treating selected conditions and establish practice guidelines. The product could be a reference tool providers may use to avoid ordering "unnecessary" services-probably including clinical lab tests.

The ostensible reason for the effort is to improve the quality of U.S. health care, although some providers are worried it may ultimately be used to cut reimbursement for procedures deemed unnecessary.

Many doctors are concerned that standardizing patterns of care may tie their hands with what amounts to "cookbook" medicine . It's conceivable the Government could, for example, tie reimbursement to the number or type of tests ordered for a given health condition.

Some analysts believe the real issue buried in the quality debate is not quality per se bu "value." That is, whether a given test or procedure benefits the patient, given its cost, or whether it could be eliminated without compromising the medical outcome.

To William Roper, M.D., former HCFA administrator and current White House health adviser, value describes the entire context of the initiative he has championed. "Value is the idea of quality services, effective services rendered in a quality fashion with due attention to the cost and medical considerations," he stated in an interview published by the Federation of American Health Systems.

Definitions of "what works" are being pursued along several tracks by HCFA, the Public Health Service, the Health Resources and Services Administration, and the National Institutes of Health. The general thrusts include: * Use of Medicare claims data and peer review information to examine the benefits of specific medical interventions.

* Funding of private and public sector research and demonstration projects to examine the appropriateness and effectiveness of treatments.

*Releasing additional Medicare data for public research into quality assessment.

Dr. Roper continues to be a strong advocate of the effectiveness initiative, but at press time he was without a top ally at HCFA. The agency's administrator post continued vacant through the summer months after leading candidate Drew Altman bowed out ot' the running.

Next in line for approval could be Charles Kahn, a minority staff member of the House Ways and Means Committee, or Ed Mihalski, a staff member of the Senate Finance Committee.

The background of either man would prove helpful in working with Congress, which is currently considering funding proposals for the initiative.

The plan has a powerful supporter in Senate Majority Leader George Mitchell (D-Me.), who says, "The rapid development of medical procedures has not been accompanied by adequate efforts to prove their effectiveness, appropriateness, and their relative value and cost."

Adds Sen. John Chaffee (RR.I.) "If we are to get skyrocketing health care costs under control without sacrificing quality care at the same time we try to meet growing health care needs, we simply must get a better handle on what works and what doesn't."

The Administration has asked Congress to fund the initiative with $52 million for fiscal year 1990. The Senate bill cosponsored by Mitchell and Chaffee would sweeten the pot to $54 million in 1990 and $110 million by 1992. A House bill introduced by Rep. Willis Gradison (R-Ohio) would allocate $72 million in 1990, increasing to $270 million in 1995.

A portion of the funds up for approval would go to private researchers involved in similar work. A leading candidate for a grant might be the Rand Corporation, which is attempting to analyze outcomes of about 20 common tests and procedures.

Rand was hired by the American Medical Association to produce data that could be used to construct practice "parameters," a word carefully chosen because it does not imply all the rigidity of such terms as "standards" or even "guidelines." These parameters would be designed to maintam and standardize care by helping doctors and patients weigh various treatment options. The ambitions are costly: Rand estimates the total price tag of the research will be at least $100 million over an open-ended time frame.

Observers say the parameters could help reduce geographic variations in the use of services, offer payers more assurance of medical appropriateness, and provide some protection from professional liability.

AMA officials, however, are more cautious and say there is no guarantee the project will reduce national health expenditures. In some cases, it may rationalize provision of a service and prove its value.

Physicians and other providers are thus trying to exercise some control over forthcoming medical value judgments. Hospitals have been among the most concerned by the increasing flow of qualityrelated data reaching insurers and other organizations. For example, the Joint Commission on Accreditation of Healthcare Organizations recently announced it will release selected survey information on hospitals that fall to gain accreditation. It's uncertain whether this might include data on such hospitals' outside service contractors.

Facilities worry that such information could be misleading and damaging if, as seems likely, it eventually becomes available to the public.

The American Hospital Association's board of trustees recently issued a policy statement reading, in part: "The AHA actively supports the public availability of useful information related to the quality of health care services. To be useful, however, quality information must be suitable to its purpose and must be prepared and released in a fashion that enables the public to make valid observations. "

The AHA board put forth a set of conditions for its support of any group that publicly releases qual ity of care information by specific institutions. Among them are the following: *All data must be accompanied by descriptions of the method of preparation, along with a plainEnglish interpretive guide on uses and limitations of the data.

* Agencies should explain the intended uses of the data and should consult with providers on the suitability of methods of collection used.

* Information should be made available only if its value to the public outweighs its potential harm. For example, data should not include individual patients' identities or peer review or quality assurance records.

* Providers should be notified before publication of any such data.

* All parties releasing information should be held accountable if they fail to exercise "due care" as described by AHA criteria.

What Dr. Roper and other Administration officials find politically difficult to say is that it appears possible to apply results of the effectiveness initiative to reimbursement policies. The possibilities have taken an intriguing twist in light of this year's Federal budget debate.

In a fairly radical move, the House Ways and Means Committee approved expenditure targets (ETs) for Part B physician payments at $30 billion for fiscal 1990. Doctors blasted the measure as health care rationing. Some analysts, however, believe such caps may prove increasingly popular as a means of allocating tight funds.

In such a scenario, the two initiatives could prove a convenient fit: expenditure targets to tell providers how much they will pay, coupled with effectiveness research to explain what they will be paying for-and why.

Medicare studies jump in independent lab payment

Medicare payments to independent clinical laboratories increased nearly 30 per cent from 1985 to 1986, more than triple the rate of growth for physicians' office labs, according to a new research study.

A review conducted by Washington, D.C.-area consultants and published by Project HOPE said that combined payments to both types of facilities increased from $814 million to $977 million during that year.

Most of the growth was attributed to increases in the number of tests per Medicare beneficiary. Test fees and volume per enrollee each rose approximately 2 per cent. Researchers based their findings on Medicare Part B data files.
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Title Annotation:Washington Report
Publication:Medical Laboratory Observer
Article Type:column
Date:Sep 1, 1989
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