Dr Mark McClellan has left his post as administrator for the Center for Medicare and Medicaid Services (CMS). On his way out he talked about the future of the Medicare program, his views on the benefits of market-based competition, and his prediction that we are in what will be known as the biomedical century.
McClellan has garnered relatively positive reviews from across the political and editorial spectrum. By all accounts he is smart, dedicated, and a good person. That last is from a reader who knows the family and respects them. While that may all be true, I’m afraid McClellan missed a great opportunity. While he has worked diligently to promote data collection, quality and performance monitoring, and investigations of pay for performance, I have not seen much direct attention paid to practice pattern variation.
That’s a big miss.
Oct
13
Since doctors drive virtually all healthcare spending via hospital admissions, ordering tests, giving prescriptions as well as consulting with patients and doing procedures themselves, it seems that with modern information technology, there is enormous potential to track total healthcare utilization by doctor. Since there are, indeed, enormous differences in practice patterns due to everything from defensive medicine to heavy utilization of expensive equipment owned by doctors to local custom, we should attempt to identify the high utilizers. When we do, their practice patterns should be flagged, challenged and publicized with a goal of narrowing the difference between the best practicers and the high utilizers. If the high utilizers can’t or won’t change their practice patterns to become more cost-effective doctors, then Medicare and/or private insurers should threaten to drop them from their networks.
The problem with this approach is that physicians do not control the access to their offices. Attempts at control to utilization have uniformly been ineefective and inappropriate. The issue is not physician driven issues. The problem is patients have little understanding of their problems and DEMAND diagnostic tests etc. When patients become less litiginous and understand that their physicians are on their side perhaps the issues will change. In the meantime, attempts to derive databases noted above will only serve to confuse patients as the patient population served by physicians differ widely even in the same regional location.