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While much has been said in this election year about the many uninsured people in this country who do not get enough health care, less has been said about those who get too much. Americans are great consumers of everything from Big Macs to MRIs, and, according to a recent study by Wennberg et al, you can add days in the ICU to that list.
The researchers (see article ” Huge Variation in Protocols Among Top Hospitals ” in STAT Read) used Medicare claims data to monitor provider performance among patients with three severe chronic diseases: chronic obstructive pulmonary disease, congestive heart failure, and solid tumor cancers. They studied decedents who had received care only at those top academic hospitals that had been named as a “best hospital” in US News and World Report . Tremendous variation was identified among providers, even those in the same geographic area, with respect to all indicators, including the number of days spent in the ICU and the number of specialists the patients saw. The bottom line is this: outcomes were not improved based on the amount of care a patient received. In fact, the researchers found some indication that patients who received a greater amount of care may have fared worse.
The real significance of this exercise is probably not which patients fared the best, as all of them are no longer with us. Rather the study’s significance lies in the methodology used to identify care that is unnecessary as well as its implications for payors and providers. In their discussion, the researchers concluded that this method could be used to find “relatively efficient providers,” configure and evaluate provider networks, and design and evaluate “pay for performance” strategies.
The likelihood that such parameters will be used to measure the effectivenessand necessityof imaging is great and has profound implications for not only radiology, but all of the many specialists who are installing technology in their offices and imaging their own patients. Overutilization in these settings is rampant (see cover story ” Update: The Self-Referral Fight Widens “) and already attracting the attention of payors, including Medicare.
Wennberg et al suggested that hospital-specific patterns would prove useful in providing benchmarks of efficient practice. But surely there is a potential role here for patients. Educating patients to understand that more is not necessarily better will not be an easy task. Burned by care-withholding HMOs in the ’90s, patients typically equate more expensive tests with better care. And the older we get, the greater the number of days on the calendar that are spent in physician’s offices in pursuit of that heady elixir: health. So when a patient walks through a physician’s door or through the pneumatic entry of their local hospital, the inclination is to say, “Supersize me.”
Measuring the effectiveness of care, with respect to both outcomes and cost, is poised to become more than an academic pastime: it will become a way of life. Those physicians who resist efficiency and quality care protocols by maintaining that health care should be left to the discretion of the physician will run the risk of being perceived as arrogant. I would be among the first to acknowledge that there is an element of art to the practice of medicine: it is the patina that develops over years of practice and learning, a practiced intuition that guides decision-making. However, it is no longer acceptable in medicine to ignore the evidence, and setting clear standards of care that are replicable from physician to physician, and hospital to hospital, is within our reach.
Cheryl Proval
