Last week’s post on guidelines elicited quite a bit of discussion – both public and private, with many vendors/suppliers/writers weighing in on the subject of what works; the practicality of guidelines and the various research methodologies and their validity.
I had a conversation yesterday with a very well-respected researcher that made me realize the post missed a critical point – without the statutory/regulatory ability to enforce/use/require/mandate/give weight to guidelines, they’re nowhere near as useful as they should be.
That’s not to say guidelines without legal ‘enforcement’ authority aren’t still helpful – there’s solid evidence that suggests sharing guidelines with providers can lead to altered practice patterns over time. I worked with a PBM client some years ago on a project involving sending letters to physicians with prescribing patterns that were well outside norms (primarily lots and lots of Schedule II drugs); there was a statistically significant change in prescriptions in the 90 days after the letters went out. Not huge, but significant.
For guidelines to really be effective, adjusters, PBMs, and employers:
a) need statutory/regulatory language that provides ‘weight’ to guidelines that meet stringent criteria in determining what drugs are appropriate
b) must provide the treating provider with claimant- and condition-specific guidelines if and when they disagree with the course of treatment prescribed by the treating doc
c) should be required to discuss the options with the treating provider, with a pharmacist or physician tasked with reaching out to the provider and provide those guidelines when requested
d) need to have the statutory/regulatory authority to not pay for drugs if the treating provider doesn’t respond or refuses to alter treatment in the face of accepted guidelines.
Jan
19
Great follow up . Binding Utilization is key to limiting abusive treatment patterns. Guidelines alone can never keep pace with best practises or take into account the complexity and varity of all patients in the system. Peer to Peer specialty match interaction with an appeal process gives the guidelines the flexibility to be really useful.
Very good followup, Joe. In my experience in UR/UM, I agree whole heartedly that without regulatory/statutory mandates UR/UM is not nearly effective (in workers’ comp, at least). The statutory/regulatory change that comes to mind is the limitation of PT/chiropractic visits implemented in CA. This provided huge savings in the state without the anticipated downside.
As you stated, there is a sentinel effect of a third party causing a treater to reflect on his/her treatment recommendation effectiveness. Also, a treater in many cases may not know the exorbitant cost of a treatment, drug or diagnostic test and agree to an equivalent more cost effective alternative. Peer to peer interaction (verbal) definitely improved buy in from the treater but it was quite common for he/she to forget to carry out the agreed upon changes.
UR/UM companies commonly issue denial letters to treaters (in WC) that would be ignored, overturned in the judicial process or overlooked by bill review and paid. Many of the savings reports would not reflect the failure of the UR/UM to actually provide savings in these instances. In other words, just because you have denied it, does not mean that you didn’t pay for it. But, conversely, you did ideed pay for the UR/UM services and the excess temporary disability payments incurred while sorting out the agreed treatment.
All these factors should be considered when evaluating cost effectiveness.
The insurance industry has missed the obvious; carrots change behavior.
Insurers have the data to document which providers are getting good outcomes, and who is providing high value care- who is getting good outcomes at low cost. The needed change is simple- share part of the savings with the good guys, and watch behavior change overnight. There is a lot of literature about this.
You also know the good patients and the behaviors that make them good patients, e.g. taking their medicine, keeping appointments, exercising, not smoking, etc. Share the savings with these folks too.
A 3-way system of aligned incentives for high value behaviors, shared by doctors, patients and employers, is especially powerful; this is also is well documented.
Insurers have proven over the last 25 years that third party care management does not add value. Guidelines are a continuation of this stick mentality. In fact, the system does more of the things that get high reimbursement, even if there are much less costly things that would solve the problem. An “inspection” model of quality improvement to improve the quality of these costly things is wrongheaded. Data driven process improvement that focuses on the desired outcomes is the Demming way to quality and value.
Consider this fact: A good internist can now almost completely eliminate heart attacks in her practice, but MI is still a leading cause of death. Why? (1) It costs the doctor a lot of uncompensated time to achieve this good outcome; she must understand the person biochemically and interpersonally and motivate the right behaviors and meds, and (2) the doctor has fewer highly paid procedures and visits to the coronary ICU to bill for. Our health care systems get more of what it pays more for, treatment of heart attacks.
The value of guidelines is limited, because they are by nature reductionistic. We need a wholistic approach, which require a smart primary care physician who can make all the right diagnoses (usually there are several) and integrate all the issues into the right plan for each patient.
Cook book doctoring is a lot worse than cook book cooking; MacDonald’s food is prepared using very rigid guidelines.
Carrot for good outcomes, by any means, rather than sticks to do the wrong things right, is the way we must go.