The Real Secret to Controlling Health Care Costs

With the debate on health care reform in full force, it's notable that the proposed bills all focus on extending coverage but do not have credible plans for controlling costs. It's a matter of the greatest national urgency to provide universal coverage, but we can't do it without bending back ever-rising cost curves. Reversing the escalation of health care costs is going to need more than legislation, yet it can be done without imposing rationing as critics of reform fear.

The key to understanding how this can happen begins with recognizing the crucial distinction between providing good care to one patient at a time, and managing whole patient populations for good health outcomes.

As an example, let's say you're diabetic and you're seeing your family physician for your annual checkup. Your doctor can tell you how well or poorly you're doing in managing your chronic disease over time. Patient by patient, the quality of health care by family physicians in this country is pretty good, and, of course, the goal of universal coverage is that everyone have access to a primary care physician.

But now, let's look at diabetes management not just for you, but for all the diabetics in your physician's practice, who number in the hundreds. If one asks how well or poorly are they doing as a group, there's no good way to know. The information is in the wrong form, scattered across the hundreds of disparate paper records that 97% of small medical practices still use. Since most of the total cost in our health case system has to do with management of chronic diseases like diabetes and hypertension, this choice of example is central to the cost management issue.

A typical medical practice is like an old-fashioned business which keeps all of its records on paper. It can probably track down any individual transaction if it needs to, but it's basically helpless when it comes to overall measurements of performance. And that's the big problem.

What would make a difference is if the physician had patient data in electronic medical records (EMR's). Beyond the value of EMR's for individual patients, those that permit data aggregation are indispensable to assessing overall performance.

It's a significant peculiarity of the world of routine medical care that such aggregate performance measures are not only unavailable, but regarded as unimportant or even unwanted.

Worse, many existing EMR's are in fact really billing documentation modules used for managing insurance claims and not in the least useful for tracking population health. But with the right kind of EMR, it would be straight-forward to determine measures of the health of a particular population or sub-population.

Why does this matter? It's not as if the legacy health care software vendors are itching to bring these capabilities to market or that their customers who manage medical practices are clamoring for them either.

It matters because once performance can be measured, it opens up the possibility of reforming payment systems to pay for outcomes (outputs) instead of inputs (office visits, lab tests, etc.). If a physician can improve the overall health of diabetics in their panel, they could be paid more. Even if we wanted to base payments on this today, we couldn't, but with the right information technology infrastructure we could.

Physicians today, as human beings, are not exempt from the perverse economic pressures created by fee-for-service regimes to see more patients for shorter appointments and order more tests and procedures. If the incentives were changed to pay to foster better health outcomes, I am convinced physician behavior would change over time.

Of course, putting such a system of payment reform in place would be a huge undertaking. To get to the starting line, though, we need to be able to measure population health, and that's where information technology can play a crucial enabling role. Therein lies the real hope for controlling medical costs.

The culture of the practice of medicine, however, is enormously resistant to this approach. There's a great deal of suspicion and misunderstanding about IT among practicing doctors. One hears things like, "I don't want to be turned into a data entry clerk, and I don't want some machine between me and my patients." It reminds me of what I heard from managers and executives a generation ago about personal computers. "I'm not going to spend my time typing at a keyboard. That's for secretaries and clerks. It's wasteful and inefficient."

Another contributor to the problem is an over-insistence on medicine as an art, which therefore does not lend itself to outcomes-based assessment. While there are plenty of hard cases in which experience, human judgment and intuition are terribly important, there are many opportunities to provide basic health care services in more efficient ways and to use IT to help measure effectiveness. We have to get serious about this if there is any hope of controlling health care costs.

Follow Mitchell Kapor on Twitter: www.twitter.com/mkapor

Comments

[EHRScope-Leslie]

I just realized that at $589,000,000 to help physicians with their EHRs, that's almost $1,000 for every practicing doctor in the country. At http://www.ehrscope.com they start the process for free. Wow - what a difference!

-Leslie

[DestinationsUnknown]

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We ignored Australia and England- look at the dumb down we got!

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72% of Americans want Public Option

[EHRScope-Leslie]

So, using the concept that medicine is not really an art, one could come to the conclusion that many of the medical practice guidelines promulgated by various medical societies should be adhered to religiously.

Let's take back pain, as an example. There are guidelines that might say that Trigger Point injections are inappropriate, but that chiropractic manipulations are helpful. While not wishing to denigrate chiropractic manipulations, and they can be quite helpful, having used thousands of 27 gauge needles with a little bit of lidocaine, I can certainly state that patients return year after year for their benefit. Therefore, being told that they are not helpful, not appropriate, and won't be reimbursed certainly came as a surprise, both to me and to my patients.

So EHRs can be helpful to constrain the treatment of physicians. However, with hundreds of them available, it would seem that the guidelines provided by any individual EHR will likely be different than the guidelines provided by others.

Will the government and/or medical societies evaluate the guidelines for treatment within each of the hundreds of EHRs available (see www.ehrscope.com for a list of over 300!)? I don't think so.

Therefore, of how much assistance will EHRs be when trying to make medicine a science rather than an art?

Just wondering today...

[fumdazzle]

Before IT-based tracking can work, reform must center on changing how the delivery system works. The pivotal question here is: Who is managing clinical decision-making by America’s huge oversupply of medical specialists? Today, the answer to this question is, no one. Fixing this requires radical changes. The status quo in health care will not change unless this core problem is effectively solved. President Obama appears to know who manages clinical decision-making at the Mayo and Cleveland Clinics. Within these two outstanding clinics a primary physician, trained as a generalist and operating from the point of first contact, functions as the general manager of clinical decisions made in all sectors of medical care, assuring that the right thing will be done for their patient, at the right time, in the right way, employing the right resources -- the classical “Four R’s” constituting the golden rule of good medicine. No less than this should be done for every patient, and certainly no more. The lessons learned from these two highly respected clinics should be used by the President as his principal reference point for a wide-ranging primary care-based initiative.

The Administration must first focus citizen attention on the differences between specialist physicians and physicians trained as generalists, and then proceed to build a well-informed public opinion about the necessity for resituating the general physician as the manager of clinical decision-making in all sectors of medical care. If trust of physicians becomes the issue, trust the generalist.