The healthcare reform environment and the drive for improved value have created a critical need to ensure physicians deliver evidence-based and cost-effective care that produces predictable outcomes. However, extreme variability continues to exist from institution to institution and from physician to physician.
The variability inherent in today's practice of medicine is an artifact of physicians' training. It's the result of a culture of medicine that suggests medicine is an art, and that physicians can distill the abundance of medical knowledge into the most appropriate treatment for each individual patient. The fallacy of these beliefs is now well proven, but the unwanted results persist: unpredictable variation in the use of the most effective treatments, resulting in unpredictable complication and mortality rates and unpredictable and uncontrolled costs.
We can refer to the playbook from the 1990s managed care period to gain insight into some of the more effective tactics used to address challenges-specifically, the tactics that successful organizations in advanced markets used to achieve high levels of performance in utilization management, cost control, and chronic disease management. Here are seven tactics that should produce good results for hospitals today based on the approaches top-performing organizations used in the '90s to reduce practice variation.
Strongly Promote the Use of Clinical Decision Support Tools
Tools that support clinical decision-making make it easy for physicians to order appropriate, evidence-based treatments. These tools include practice guidelines, clinical protocols, order sets, rules and alerts, and hard stops in electronic health records (EHRs). They are delivered at the point of care, on paper, or in the EHR, and embody the most up-to-date, evidence-based treatments. To ensure widespread adoption among physicians, an appropriate development and consensus-building process is needed. Medical directors play a critical role in this area.
Insist on Only Evidence-Based Medicine
The immense volume of medical literature makes it impossible for physicians to stay up to date on the most effective treatments without significant help from practice support tools. The content for these tools must come from a well-respected resource that is readily available online and that provides concise, easy-to-use summaries of up-to-date clinical content and best-practice guidance. The best providers of such tools deliver content developed by teams of physicians, nurses, and pharmacists who review and summarize peer-reviewed literature and best-practice guidelines. They apply a methodology that ensures unbiased coverage of the most trustworthy research, and their clinicians update the summaries regularly so that current, reliable information is available to clinical decision makers.
Encourage Your Medical Directors to Become "Objection Busters"
Getting your physicians to embrace standardization and to practice evidence-based medicine can be difficult. The first hurdle is to overcome common physician objections. You've likely heard them all: "My patients are sicker"; "Medicine is an art"; "I won't practice cookbook medicine"; "We need an EHR to do this"; "Your data are crap"; and so on. It's up to your medical directors and physician leaders to counter these objections. Your physician leaders and quality staff need to be informed and comfortable in handling the objections. They need to become "objection busters."
Manage Your Formulary Aggressively
Aggressive formulary management ensures the availability of the most clinically effective and cost-effective drugs. Providing this information in a formulary guide supports standardization and predictable pharmaceutical use. Formulary information should include drug cost as well as equally effective substitutions. When physicians know the cost of all treatments, they often make more cost-effective decisions. There's no need to reinvent this work: Your local health plans are experts in this area and are willing to provide a helping hand.
Manage Devices Aggressively
Despite our best efforts, our supply partners continue to find inventive ways of getting new products into our organizations through the "back door"-i.e., bypassing our value analysis teams, our technology assessment departments, or pharmacy and therapeutics committees. In the past year, we learned that two new, expensive biologicals had made their way into our institutions. For both products, the literature support is unclear, and we are not confident that their use is consistent with evidence-based research. Staying in front of these issues is the best way to ensure that patients receive clinically sound and cost-effective treatments.
Develop Action Plans for Reducing Variation
In the late 1990s, we initiated a cost-reduction strategy involving physician-driven projects we call "medical action plans." Cost savings achieved through these projects are derived from standardization of medical practice. The initiatives have effectively reduced variation among physicians and have generated millions of dollars in cost savings. Examples include standardizing use of central lines and swan ganz catheters, standardizing transfusion criteria for total joint replacement patients and procurement of autologous blood, and establishing guidelines for use of intraoperative cell savers. Management of the plans rests with the chief medical officer, with support from the heads of utilization management and quality. Individual initiatives are led by the appropriate medical director and become part of the physicians' annual performance goals. To promote the best possible results, the estimated savings for each project is embedded in the appropriate department budget.
Limit Access of Sales Reps
The pharmaceutical industry's sales representatives are experts in a science called academic detailing. And, yes, it's a science-involving use of sophisticated tools that are extremely effective at changing physician prescribing patterns. The problem is that these reps' efforts can be one of the primary sources of physician practice variation in our organizations. These reps are well informed. They know our physicians' prescribing patterns better than we do, and they use this information to craft sophisticated academic detailing plans to influence our physicians' choice of treatment options. They also are very effective. Why else would pharma spend billions of dollars on this approach each year?
The only way to maintain control of your environment is to lock these sales reps out of all of your facilities and physician offices, unless their products are on your formulary and device lists, in which case you should insist that the reps help detail your clinicians on appropriate use guidelines. Sales reps for approved pharmaceuticals and devices can be an invaluable resource to accelerate implementation of your practice guidelines and appropriate use of your formulary.
Lessons from the Past-for the Future
Many hospitals face a difficult task in persuading physicians to embrace the principles of evidence-based care and participate actively in efforts to eliminate unpredictable practice variation that does not support improved outcomes. Yet improving the value of the services they deliver depends on their ability to get physicians onboard. Many of the tried-and-true principles that worked well in the 1990s remain viable for hospitals today as they meet these challenges posed by healthcare reform.
John Byrnes, MD, is senior vice president and chief quality officer, Spectrum Health System, Grand Rapids, Mich.; clinical associate professor, MSU College of Human Medicine, Grand Rapids; and a member of HFMA's Western Michigan Chapter.
Publication Date: Monday, April 02, 2012