News | Cost of Care

Health Plan, Practices Focus on Care Overuse

News | Cost of Care

Health Plan, Practices Focus on Care Overuse

Jan. 25—Although cost and quality are common features of value-based payment, a less common component is ensuring the provision of appropriate care.

The insurer learned that practices wanted to openly share their clinicians’ data among all the physicians in the practice, so they could compare results.


Jan. 25—Although cost and quality are common features of value-based payment, a less common component is ensuring the provision of appropriate care.

But a Tennessee insurer, BlueCross BlueShield of Tennessee (BCBS Tennessee), is piloting such a model and finding positive early results.

“The key to our approach has been engagement,” Michael Drescher, director of provider engagement for BCBS Tennessee, said about an appropriate-care pilot that the insurer has operated at three practices for several months.

Drescher and others discussed the issue this week in a webcast hosted by the National Institute for Health Care Management (NIHCM) Foundation.

The insurer approached three cardiology practices about sharing data on the practice patterns of each clinician in key areas where the Practicing Wisely campaign has identified appropriate care.

The physicians generally responded positively to the proposal, but some were skeptical because they viewed it as another measurement program among myriad others.

But the use of a universally accepted, clinically validated yardstick like Practicing Wisely improved clinicians’ receptivity to the pilot, as did the practices’ use of physician champions who served as a conduit between the health plan and clinicians, Drescher said.

Drescher said physicians at the practices have been “generally positive” about the initial rounds of data shared with them, and the insurer is watching to see how the data changes both their practice patterns and their feedback.

“My belief is that the reports themselves trigger behavioral change and don’t require carrots or sticks,” Drescher said, referring to the lack of any financial consequences from the reports.

The insurer purposely selected practices that are still largely dependent on volume-driven fee-for-service payments, thinking that if the pilot could affect treatment overuse in such practices, it was very likely to drive changes in other practices that are heavily invested in value-based payment.

The pilot aims to move the appropriate-care movement beyond previous efforts by individual practices to adopt medical society-derived appropriate-care standards. And it could have big financial repercussions.

The scale of the appropriate-care challenge, said Marty Makary, MD, a surgical oncologist and chief of the Johns Hopkins Islet Transplant Center, is illustrated in the data, including a doubling in the number of prescriptions issued nationally over the last 10 years.

“Did disease double in the last 10 years? No. Many people say we have a crisis in the appropriateness of prescribing,” Makary said.

To address the overuse challenge, Makary helped develop guidelines around the number of procedures that should be used to remove a skin cancer lesion, collected data on how 1,000 surgeons performed against their peers on that practice, shared the data with the surgeons, and collected their feedback.

The feedback was positive, and a coming study estimated that changes in practice patterns by surgeons who participated in the initiative nationwide would save the Centers for Medicare & Medicaid Services $22 million.

“We braced for most people to be angry that they received a performance report; instead they thanked us for being able to see the data,” Makary said.

Overcoming Hindrances

Ty Gluckman, MD, medical director of clinical transformation at Providence Heart and Vascular Institute in Portland, Ore., said many physicians’ practice patterns are formed by inertia, some haven’t kept up with the latest science, and many practice in silos—even if employed by a hospital or health system.

Although some hospitals and health systems have shared data on varying practice patterns among their clinicians, many organizations don’t have the ability to aggregate that data in a usable way, Gluckman said.

“Having transparent and nonpunitive data allows you to see where you sit in the spectrum of providers,” Gluckman said.

The biggest impact such data has had on Gluckman’s approach to his practice is that it has increased the amount of time he has to spend discussing with patients why his practice patterns changed and informing them that the changes are based on the best data.

Others describe the need to regularly dissuade patients from prescriptions that they are demanding after being influenced by advertising but that they don’t need.

Lucy Liu, a principal at Oliver Wyman who advises health systems and payers on value-based payment, said a focus on appropriate care can improve both cost and clinical outcomes.

She cited Walmart’s analysis of employees’ health data that found one-third of their care was unnecessary or even dangerous. Specifically, 30 percent to 50 percent of workers who thought they needed spine surgery did not need it, 10 percent were falsely diagnosed with cancer, and 30 percent who were diagnosed with cancer had the wrong treatment.

In response, the massive employer developed relationships with centers of excellence, where patients were sent for many surgeries.

Other Findings

Among the interesting early findings in the BCBS Tennessee study was that practices used the data to discuss their overall practice patterns and why they had outlier results compared to other practices in their area.

The insurer also learned that practices wanted to openly share their clinicians’ data among all  physicians in the practice, so they could compare results.

“There is a desire to practice better, but they lack the tools to do that and this a tool that we bring to help have those conversations internally,” Drescher said.

Makary said some physician frustration has stemmed from various process measures that impact their ability to tailor care to specific patients.

“This was an attempt to find reasonable boundaries for variation,” Makary said, referring to an approach that displays individual physician performance on a given practice pattern among a spectrum of other clinicians—and only highlights outliers that are more than two deviations from the mean.

The approach aimed to encapsulate the mindset that “variation is good but within boundaries,” Makary said.

Makary said the approach cannot adjust outcomes for sicker patients, so instead it allows for a range of appropriateness in practice patterns for practices or physicians who believe they have sicker patients.

“It may be that there are physicians who are outliers for appropriate reasons,” Makary said.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

About the Authors

Rich Daly
HFMA senior writer/editor

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