It has long been known that medical care delivery can vary dramatically from state to state, and even within a state. Jack Wennberg and his colleagues at Dartmouth have reported deep and long on the issue, with the initial revelation – and it was that – coming forty years ago. The latest work can be found at the Dartmouth Atlas of healthcare – and it is well worth visiting.
So, here’s the deal – medicine is as much art as science, driven by local knowledge and personal beliefs as much as by best practices and evidence-based clinical guidelines. While we like to THINK it’s about science, it often isn’t.
WCRI’s Dr Rebecca Yang delivered the initial presentation at WCRI’s annual meeting focused on interstate variation in medical care. Their analysis looked at surgery, MRIs, pain management injections, and physical medicine; a few highlights (for those not able or willing to make it to Boston this year) include:
- Surgical rates varied from about 18 percent in Massachusetts to 38 percent in Indiana.
- MRIs of the lumbar region had an even larger range, from 18% in MA to 50% (FIFTY PERCENT!) in Florida; Florida’s rate was 20% (8 points) above the next highest state.
These data raise multiple questions; do the UR requirements in MA have anything to do with the lower rate of surgery? Could that rate be affected by Mass’ very low reimbursement for workers’ comp surgery?
Florida has (relatively) tight managed care provisions, yet their MRI rate was 250% of Massachusetts. Both states have strong UR, and in FL employers can direct. And there’s no discernable variation in the types of injury. Which begs the question – what are payers not doing that they should be doing in FL?
And another – are there too few MRIs in Massachusetts? ( I personally doubt this, as the rate may well too high even in MA). Much more in Dr Yang’s presentation…
Ohio State Prof. Tom Wickizer followed Dr Yang. He gave an excellent background on small area analysis and practice pattern variation. he mentioned one of my heroes, Dr Jack Wennberg (noted above): and highlighted seminal research indicates “spending 50% – 80% more on health care did not lead to meaningful differences..”
Wickizer quickly pivoted to matters of specific interest to WC, discussing the wide variation in back surgery rates across the nation; there’s a nine-fold difference in the lumbar fusion rate between the northeast and the west…(which says don’t bother pre-certing in New England, but pre-cert every case in the southwest).
So, how does one “fix” this? Well, guidelines can help improve results – if they are used. Wickizer said adherence – the usage of guidelines – is often less than 50 percent. There are a number of reasons for this, but not many are very good (a few are valid). And, adhering to guidelines does lead to improvement in functional outcomes and better health – although it’s not a dramatic difference (Feuerstein study, 2003). There was a larger impact in a study of the impact of PT guidelines, with costs and pain rating much lower and better outcomes as well.
All that’s well and good, and it indicates that guidelines can and do help – but they have to be used. And getting providers to follow guidelines is very difficult – unless you force the issue. The state of Washington did just that, and delivered better outcomes and lower costs way back in the early nineties… and those better outcomes included lower disability payments. One can, and probably should, infer that better medical care delivers lower medical costs.
Thereby “proving the meme”…
Joe, your post today continues to highlight a known issue. But adding to the challenge on the providers adhering to the guidlines is there really is no incentive for them to do so. So the member/patient/injured worker follows the advice of the smartest guy in the room and has the procedure that the doctor recommends. Educating the member/patient/injured worker directly AND involving them in the decision making process can and DOES make an impact. Shared Decision Making has been shown to reduce surgeries through conservative therapies first – with NO harm to health.