Medicine under scrutiny: Employers are looking to evidence-based medicine--that is, quantified research on treatment patterns and outcomes of health care services and procedures--as a way to help control costs. (Special Report: Managed Care).
"There's almost an incredulousness on the part of many employers that a lot of medicine is practiced without any scientific basis at all," says Michael Bailit, president of Bailit Health Purchasing LLC.
Bailit is the producer of one of two new initiatives in the area of EBM coming out now. Bailit has published a report on 11 new ways of compensating health care providers to improve health quality. The report is being produced by the National Health Care Purchasing Institute. The other effort is the ongoing work being done by the Leapfrog Group, an EBM-advocacy organization founded in 2000 by the Business Roundtable, sponsored by Fortune 500 employers such as GE, GM, Verizon, and the Pacific Business Group on Health, as well as the Centers for Medicare & Medicaid Services (CMS). Leapfrog, which is advocating for three important measures that could universally improve quality, is also compiling a voluntary national online survey, which currently lists information from 300 hospitals on how they've implemented the three "leaps."
"Over the next couple of years, we plan to have a comprehensive database," says Suzanne Delbanco, executive director of Leapfrog. The group has grown from seven members to more than 100 in less than two years, emphasizing the importance of EBM to large employers.
Besides the new offerings by the Institute and Leapfrog, there are a wide variety of other tools employers can look to make sure they are getting the most quality, and the fewest preventable accidents, for their health care dollars. Semipublic organizations such as the Joint Commission for the Accreditation of Health Care Organizations and the National Committee on Quality Assurance accredit organizations on various criteria or offer a database of information on providers and health plans. The concept has spawned a veritable growth industry in the analysis of how providers can improve quality. Although derided in the medical community as "cookbook medicine," clinical practice guidelines give providers standards for the treatment of common illnesses, particularly in the area of chronic disease management.
As simple as the concept sounds, evidence-based medicine grew out of the realization that, for all the scientific basis for much of modem medicine, much of what is going on in the field today is done without the benefit of proof in the form of clinical studies, articles in peer-reviewed journals, or formally quantified research or comparison of any kind. Quantified study of treatment patterns can have real implications for cost control as well as outcomes. For example, a prescription for a slightly more expensive, newer antidepressant can reduce system costs elsewhere because depression is associated with chronic illness, and effectively controlling the depression tends to improve treatment compliance, studies have shown.
Three Great "Leaps"
The Leapfrog Group places great emphasis on its three measures for quality performance. Though the IOM report initially produced a large number of quality improvement suggestions, these three have been most thoroughly tested. "We commissioned a report by the Dartmouth Medical School to study the economic impact of adopting the three practices. Overall, they found adoption could save the health care system as a whole $9.7 billion dollars," says Delbanco.
The three leaps are computerized physician order entry, which studies suggest could reduce serious medication errors by 86 percent; intensive-care unit staffing by specialists known as "intensivists"; and evidence-based hospital referral, an area where employers may have more than average control.
"This last suggestion is based on the idea that patients who need high-risk surgeries or neonatal care should choose hospitals based on publicly reported, risk-adjusted data; because the data is not always available, we're using volume as a proxy," says Delbanco. For example, she says, the suggested minimum volume for a coronary artery bypass graft is 500 procedures per year.
Other tools are also available to help employers select a health plan that has a relationship with the right hospital. Leapfrog is releasing data from hospitals drawn from a sample of six areas of the country. "Employers often look to the National Committee for Quality Assurance or use existing tools such as HEDIS off the rack," says Kip Piper, director of the National Health Care Purchasing Institute. "But because of politics and the visibility of managed care in the 1990s, health plans were held to a high standard of visibility, while the provider community was allowed to remain invisible. Consumers started to use provider retention as their only standard for quality, whether beneficiaries could use any provider they want," Piper says.
The Joint Commission, a quasi-public body, has also accredited 80 organizations, both managed care organizations and hospital-affiliated systems, as being Medicare-eligible and has a new program coming out for the certification of disease-management companies.
"One of the tools they put out is a way to measure the cost savings of contracting only with accredited health plans," says Piper. "You can go on the NCQA Web site and enter in how many employees you have, and what their age range is, and the NCQA will tell you the cost-benefit in terms of dollars saved, increased productivity, and decreased absenteeism," he says.
Dr. Miles Snowden, director of health services for Delta Airlines, another Leapfrog Group member, disagreed that the report cards that are available are sufficient. "The evidence doesn't exist in a uniform style," he says. "For example, if you needed a CABG performed tomorrow and wanted to look it up in Consumer Reports, you wouldn't find it there. Hospitals are not reporting the data in a public manner or in a consistent format," he says.
"The NCQA is putting out a scorecard, but it would be useless," Snowden says. "It's not specific enough regarding your particular needs at a given moment in time. Ninety percent of the organizations scored measure satisfactorily, and 10 percent scored unsatisfactorily. You're left with some non-evidence-based decision to make."
How well a given institution performs is often determined in part by a how its providers conform to the use of clinical guidelines. Despite their unpopularity with doctors, the best clinical guidelines are firmly grounded in evidence-based medicine. "The sources for clinical guidelines we've come across are scientifically valid, based on best practices accepted by medical specialty societies," Piper says. "It's not just the purchaser saying, 'We're going to define quality for you.' It's the medical community itself."
For example, "beta blockers are indicated for people who have suffered from myocardial infarction," says Maureen Potter, executive director of the disease-specific care certification program at the Joint Commission. "Beta blockers are expensive, but they can reduce costs down the line. The medications for improving cholesterol management can also improve hypertension."
The Joint Commission will be looking at a variety of factors such as these in its new accreditation program for disease-management companies. "We decided the basic model didn't need to be disease-specific," says Gina Zimmerman, senior executive director for business development at the Joint Commission. "The basic tenets that we wanted to have in place have to do with performance improvement, delivering clinical care, and making sure that providers are qualified and competent. We also want to know that a program is supporting patient self-management," she says.
Part of the problem is in getting providers to comply with such protocols in the first place. "Incentive plans can be effective," says Michael Bailit. "It's vital that there be buy-in up-front from the affected providers."
Bailit's report groups 11 proposed provider incentives into two categories, financial and nonfinancial, the latter of which can be just as effective. Some incentives have been in use for some time, such as bonuses and withholds, but there are other suggestions here too. "Other financial incentives can be reimbursement for new services such as care planning and coordination services or paying for the creation of a treatment plan for people with chronic illness." One financial incentive that is favored by GM in the context of managed care plans is variable cost-sharing for patients. "Providers who deliver higher quality could be accessed for limited or no cost-sharing," says Bailit.
Nonfinancial incentives include publicizing the provider, providing technical assistance, or even removing administrative burdens for high-performers.
"If financial incentives are used, the need is to involve an adequate amount of money," Bailit says. "If the intent is to shift volume to high-performers, there needs to be surplus volume," he adds.
Kip Piper agrees. "It may take 10 percent to 30 percent of a doctor's reimbursement target to move behavior. What happens with single withholds is that people budget them in and compare the cost of improving quality; they'll assume the 5 percent withhold is a loss," says Piper.
Dr. Brent C. James, vice president and executive director at the Intermountain Healthcare Institute for Health Care Delivery Research, agrees that changing physician behavior may be difficult, but says that the results may be worthwhile.
James says that Intermountain, a system of 22 hospitals and almost 100 outpatient clinics in the mountain states, has been making use of evidence-based medicine techniques for some time.
"A year or so ago, when the new Cox-II drugs came out, we'd been using ultram as our agent of choice." Because Cox-I pain relievers cause ulcers and internal bleeding, Intermountain had done a decision analysis on two different agents, ultram and misoprostil. "Ultram is quite expensive, but if you consider the cost of treatment for internal bleeding with a steroid, by going with ultram, the more expensive model, you save quite a bit more," James says. When the Cox-II drugs became available, Intermountain was able to build them right into its decision tree.
Intermountain can do the research because of its size. James gave another example. "We have good evidence that good sugar control in diabetes cases can reduce peripheral neuropathy, heart disease, and blindness," he says. "We can use sugar levels as a surrogate for the final outcome." James says that HEDIS measures in diabetic care relate to whether the doctor checked for hypertension and urinary protein, blood sugar at appropriate intervals, cholesterol, and as well as damage to retinal blood vessels.
"According to our research, if I'm able to invest more in tight diabetes control, I might increase my costs by between $500 and $700 per year, for slightly more expensive medicine and slightly more office visits. But if we can bring down the hemoglobin Alc count by just 2 percent, we'll see $30,000 in net savings per patient over the next 15 years. I won't need to treat the damage to the eyes, the blindness, or perform the amputations.
"The problem is that the entire savings will be a windfall to the health plan. To change the pattern of care, the action has to take place at the clinic," James says.
In a big system like Intermountain, it becomes important to arrange practice guidelines at different stages.
"We built our evidence-based protocol for diabetes care at three levels, employed, tightly-aligned, and loosely affiliated doctors," James says. "Intermountain's employed doctors use clinical work stations to record their compliance with the clinical guidelines."
John Otrompke is a recent law graduate in Chicago. He can be reached by e-mail at Otrompke@law.com.