I highly recommend reading a recent report sponsored by the Robert Wood Johnson Foundation and the Urban Institute (the employer of the authors) by Robert Berenson and Elizabeth Docteur entitled Doing Better by Doing Less; Approaches to Tackle Overuse of Services. It is an excellent analysis of approaches that address the issue of inappropriate and unnecessary services.
The report dismisses previous efforts to combat overuse including:
Measurement of overuse;
Educating physicians to comply with evidence of appropriateness;
Affecting the demand for services; and
Using administrative levers to reduce inappropriate services.
The report suggests that Choosing Wisely® is a promising campaign but untested and its potential to affect demand for inappropriate services is unclear. In slight defense of the campaign, Choosing Wisely attempts to engage physicians and patients in a conversation about resource use and waste. It approaches this issue through a modern day version of professionalism that asks physicians to be responsible for the prudent use of precious health care resources in partnership with patients and families.
Acknowledging the reality of past failures, the authors of the report suggest the need to “rely more on payment incentives. Combined with investment in production and dissemination of evidence on what works under what circumstances. To influence clinical decisions and support efficient delivery that avoids overuse and reduces the use of services offering low benefit, relative to risks, rather than on approaches that rely on measurement of inappropriate services or enforcing adherence to standards.”
The heavy reliance on payment reform as the panacea bothers me for several reasons. I just don’t think we can flip a switch and ‘presto!’ make change happen for several reasons.
1) Payment reform is just the beginning — not the end solution — of creating a more effective and efficient system. It orients practitioners away from creating volume to producing better outcomes for patients and producing better value for patients while incorporating their preferences. But still needed are:
A stronger and more effective primary care workforce;
Patient and caregiver engagement in their care;
Redesigned clinical practices with automated decision support systems, revamped admission protocols and clinical workups to weed out unnecessary care;
Better coordination of care, transitions, and teamwork;
Enhanced competencies around medical decision making and evidence-based medicine; and
Practitioners armed with communication skills to discuss why a procedure or test is not necessary with their patients and involve patients in their medical decisions.
2) What is written about payment reform doesn’t address how clinicians are directly paid. Many institutions getting paid through a global, “fixed” payment system. Other reform payment techniques don’t transfer that reimbursement philosophy to how they are paying physicians and continue to pay them on volume of services produced. Physicians paid on a salary with medium-level bonuses appear to be the most neutral payment scheme, which in turn fosters the best performance and professionalism.
3) There is an underlying assumption that money is king and health care professionals are not motivated by higher principles. In Dan Pink’s book, Drive: The Surprising Truth About What Motivates Us, the author makes the case that professionals work at their highest level when they have purpose, mastery, and autonomy (with accountability) in their work.
There is no silver bullet to the problem of overuse. While payment reform is necessary to solve the problem of overuse, we should not forget the importance of professional values, the commitment of physicians to be stewards of resources and the new competencies associated with that commitment.