Accountable Care and Evidence-based decision-                   making                  Eugene Rich MD           Director,...
Inside the DC Beltway  65 miles surrounded by reality  Beltway view of the current US Health Care   System
CBO on promoting evidence based care toaddress rising health care costs “…little rigorous evidence is available about whi...
2009- $1.1 Billion Investment in CER thru ARRA                        Stakeholder                                  Human &...
Support for CER/PCOR after ARRAPatient Centered Outcomes Research Trust  Fund   grows to $600 M per year by 2014     – $5...
Public Investment in Health Care Effectiveness ResearchAHRQ-ACA,       PCORI, NIH,        AHRQ-ACA, NIH     AHRQ,NIH, PCOR...
Patient Centered Outcomes Research Definition“Patient-Centered Outcomes Research (PCOR) helps  people and their caregivers...
PCORI Funding Opportunities   Assessment of Prevention, Diagnosis, and Treatment Options – projects    that address criti...
Patient Centered Research Questions A 47-year-old woman with rheumatoid arthritis has learned that her  primary care doct...
CER/PCOR Purpose II   Feb 2009 ARRA CER investment    was driven in part by need to    increase value of Medicare and    ...
Using CER: What’s Allowed by ACA  Dissemination:    – AHRQ charged with disseminating findings      published by PCORI an...
CMMI: Learning How to Improve Care Delivery  CMS- Center for Medicare and Medicaid Innovation    (CMMI)   $10B mandatory ...
PCOR- Research Development Challenges New understanding of the consumers of CER study  products CER/PCOR focus on answer...
Incorporating the clinical decision-maker perspective     Soliciting the insights of patients and clinicians     Incorpo...
CBO on promoting evidence based care toaddress rising health care costs “…little rigorous evidence is available about whi...
Fee for Service Payment Longstanding approach to physician reimbursement Risks well recognized   – Code of Hammurabi, He...
18
Decision-making at the Point of Care  Patients seek physicians to address their   health concerns    – And relieve their ...
Clinician incentives can bias decisions Clinician beliefs about their professional role Assessment of “prior probability...
Too Little? Too Much? Primary Care Physician Views       95%- believe physicians vary in what they do for          identi...
FFS and Point of Care Decision-making  FFS offers straightforward method to   encourage delivery of services at the point...
Imaging for Low Back Pain* High margin for imaging studies for back pain creates  incentives for physician/clinician to …...
Antibiotic prescribing in Sinus infection  No direct FFS incentive of ABX RX (in US)  FFS incentive to recommend an appr...
Treatment “under-management” for GERD   GERD Rx “should be titrated to the lowest    effective dose needed to achieve the...
Payment reform options: potential impacton evidence-based care  Revised FFS  FFS + P4Q  Episode-based payment  Global ...
Revised FFS Advantages-  – Many current fees not reflective of physician work (some over-valued, some    under-valued)  –...
FFS w/ P4Q  Advantages-   – Monitor/reward better chronic care management (eg     GERD management)   – Monitor/reward app...
23,000 clinical trials/yr = Enough Evidence?    Robert Califf, IOM Meeting, 12 December 2008. Less than 20% of AHA/ACC hea...
Heterogeneity of Treatment Effect                Diagram by J. Meddings                        (Vijan & Hayward, Ann Inter...
Stringent Dichotomous MeasuresDon’t target patients most likely to benefit  – Ignore the heterogeneity of patient risk fa...
FFS w/ P4QOverused    +/-testUnderused   √testOver DX     +/-Under DX    √Overused    +/-RxUnderused   √RxUnder-      +/-m...
Episode-based payment  Advantages-   – Single payment for all services needed during an     episode of illness   – Remove...
Who to Give the Episode Payment To? Practice environment and clinical decision-making       Collecting Data on Physicians ...
Practice environment and clinical decision-making Patients                      Physicians   – Age, gender, race/ethni  ...
Practice environment and clinical decision-making     Point of Care                Practice Organization      – Clinical...
HIT at the Point of Care  How frequently do you use a computerized or   electronic system to perform the following   task...
Practice environment and clinical decision-making   Networks and                      Market Environment,    Affiliation...
“Physicians don’t just work for money” Ability to do good- accessing/managing  resources related to what they care about ...
Changing the employed clinician’s “margin”Compensation                        Work environment % income at risk          ...
Who to Give the Episode Payment To?   Most physicians participating in episode-based    payment will be compensated by a ...
Physician Compensation Strategies and      Intensity of Care          Highly capitated practice environments had         ...
Episode-based payment  Disadvantages    – Episode-based payments may discourage evidence-      based testing and treatmen...
Episode-            based            paymentOverused    +/-             the role of episode-basedtest                     ...
Global payment (Capitation)  Advantages-   – Single payment for all services needed by a patient     during a year   – Re...
Incentives for Care of Low Back Pain  incentive to reduce patient access to expensive   clinical services  Incentive for...
Global payment Disadvantages  – Capitation may encourage reduced access and under-    diagnosis  – Capitation may discour...
Global            paymentOverused    √         •For some chronic conditions thetest                  intermediary receivin...
Revised   FFS w/ P4Q Episode-   Global            FFS                  based      payment                                 ...
Policy Goals for Payment Reform Promote evidence-based decision-making at the  point of care  – Patients seek clinicians ...
Incentive Reform to Promote Evidence-based Care      There are many mechanisms for paying       physicians; some are good...
Incentive Reform to Promote Evidence-based Care      Recalibrate productivity measures to       recognize physician costs...
For under-used, highly effective, tests or treatments  Address clinical issues    – Knowledge, diagnostic skills    – Con...
For over-used in-effective, tests or treatments  Address clinical issues  Incentive reform    – Re-evaluate for mis-cali...
Policy Goals for Payment Reform Promote evidence-based decision-making at the  point of care  – Patients seek clinicians ...
Promoting evidence based care to  address rising health care costs  – “…little rigorous evidence is available about which ...
Accountable care and evidence based decision making
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Accountable care and evidence based decision making

  1. 1. Accountable Care and Evidence-based decision- making Eugene Rich MD Director, Center on Health Care Effectiveness
  2. 2. Inside the DC Beltway  65 miles surrounded by reality  Beltway view of the current US Health Care System
  3. 3. CBO on promoting evidence based care toaddress rising health care costs “…little rigorous evidence is available about which treatments work best for which patients” – Solution: CER/PCOR And”…financial incentives … tend to encourage the adoption of more expensive treatments and procedures, even if evidence of their relative effectiveness is limited” – Solution: provider payment reform Orszag and Ellis, NEJM, Nov 2007
  4. 4. 2009- $1.1 Billion Investment in CER thru ARRA Stakeholder Human & Comparative Dissemination Needs Input & Data Scientific Effectiveness and Identification Involvement Infrastructure Capital Research Translation Horizon Community Research Evidence Data base Scanning Forum Training Generation projects Career Evidence Electronic Data Development Synthesis Management Forum Methods Development Populations Conditions Ty p e s o f I n t e r v e n t i o n sItems in blue represent components derived from the HHS CER framework, those in yellow represent components taken from theFCCCER strategic framework, and items in green represent components taken from both the HHS and the FCCCER frameworks. 5 5
  5. 5. Support for CER/PCOR after ARRAPatient Centered Outcomes Research Trust Fund grows to $600 M per year by 2014 – $50 M in 2011; $150 M in 2012 – Funding thru mandatory appropriation, and tax on private health insurance 20% to HHS and AHRQ for PCOR data infrastructure, methods development and research translation 80% controlled by PCORI – “not an agency … of the federal government” – 21 member Board of Governors – Establish and support agenda for “patient centered outcomes research”
  6. 6. Public Investment in Health Care Effectiveness ResearchAHRQ-ACA, PCORI, NIH, AHRQ-ACA, NIH AHRQ,NIH, PCORI AHRQ CMMI, (PCORI) CMMI Comparative Research Research Evidence- Infra- on polices Effectiveness on using based, Afforstructure to Research CER dable Healthfor CER promote Studies findings in care using practice CER •Medications •Medical devices and•Stakeholder technologies •Providers •Payment andinput •Medical and surgical •Patients services, regulation•Databases •Delivery •Behavioral change •Monitoring•Training strategies, Systems and feedback•Methods •Delivery system•Reviews interventions
  7. 7. Patient Centered Outcomes Research Definition“Patient-Centered Outcomes Research (PCOR) helps people and their caregivers communicate and make informed health care decisions, allowing their voice to be heard in assessing the value of health care options.”1. “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”2. “What are my options and what are the benefits and harms of those options?”3. “What can I do to improve the outcomes that are most important to me?”4. “How can clinicians and the health care system they work in help me make the best decisions about my health and healthcare?” www.PCORI.org 8
  8. 8. PCORI Funding Opportunities Assessment of Prevention, Diagnosis, and Treatment Options – projects that address critical decisions that patients, their caregivers and clinicians face with too little information (CER) Improving Healthcare Systems – projects that address critical decisions that face health care systems, the patients and caregivers who rely on them, and the clinicians who work within them Communication and Dissemination Research – projects that address critical elements in the communication and dissemination process among patients, their caregivers and clinicians Addressing Disparities – projects that will inform the choice of strategies to eliminate disparities Accelerating Patient-Centered Outcomes Research and Methodological Research – COMING FALL 2013 9
  9. 9. Patient Centered Research Questions A 47-year-old woman with rheumatoid arthritis has learned that her primary care doctor recently joined a large medical group …becoming part of the system’s patient-centered medical home. – What should this woman know about the potential benefits or possible risks of this new way of primary care practice compared to her current or other care approaches? A world-class athlete has been advised by her sports medicine physicians that she needs arthroplasty in each knee. She is referred to a group of orthopedic surgeons …that are part of an accountable care organization. – How will this organizational model impact her care, – and what information about the ACO should she know to determine whether they will be likely to honor her strong preference for treatment that will return her to maximal function as quickly as possible? 10
  10. 10. CER/PCOR Purpose II Feb 2009 ARRA CER investment was driven in part by need to increase value of Medicare and Medicaid spending, but policymakers became sensitive to public fears that CER will be used to ration care This 2009 debate affected ACA language on what PCOR is and how it can be used E.g. PCORI not to fund work that calculates “dollars-per-quality adjusted life year (or similar measure that discounts the value of a life because of an individuals disability)” Rich EC, Docteur E, MPR CHCE Issue Brief 2010 11
  11. 11. Using CER: What’s Allowed by ACA  Dissemination: – AHRQ charged with disseminating findings published by PCORI and other CER/PCOR  Clinical decision support: – PCORI/AHRQ expected to promote use of findings via automated clinical support tools  Use of PCORI findings in coverage and reimbursement decisions by public programs – findings can’t be sole input to Medicare coverage decisions but ACA does not prohibit use Rich EC, Docteur E, MPR CHCE Issue Brief 2010 12
  12. 12. CMMI: Learning How to Improve Care Delivery CMS- Center for Medicare and Medicaid Innovation (CMMI)  $10B mandatory appropriation over 10 years  Goal: better care and better health, at reduced costs through improvement…  identifying, testing and spreading new models of care and payment – Patient Care Models- eg interventions to reduce healthcare-acquired conditions – Seamless Coordinated Care- eg identifying and deploying the best advanced primary care and health home models – Community and Population Health Models- eg test new care models that impact underlying drivers of heath (smoking, obesity)
  13. 13. PCOR- Research Development Challenges New understanding of the consumers of CER study products CER/PCOR focus on answering questions relevant to typical clinician and patient decision makers Rich EC, Bonham A, Kirch D, Academic Medicine 2011 14
  14. 14. Incorporating the clinical decision-maker perspective  Soliciting the insights of patients and clinicians  Incorporating the diversity of – communities, – cultures, – patient perspectives, – practice settings  Recruiting representative research participants and settings into research networks Rich EC, Bonham A, Kirch D, Academic Medicine 2011 15
  15. 15. CBO on promoting evidence based care toaddress rising health care costs “…little rigorous evidence is available about which treatments work best for which patients” – Solution: CER/PCOR) And”…financial incentives … tend to encourage the adoption of more expensive treatments and procedures, even if evidence of their relative effectiveness is limited” – Solution: provider payment reform Orszag and Ellis, NEJM, Nov 2007
  16. 16. Fee for Service Payment Longstanding approach to physician reimbursement Risks well recognized – Code of Hammurabi, Heraclitus, Ben Franklin, GB Shaw Physician as “seller of services” – Buyer does not have physician’s specialized knowledge – Buyer further disadvantaged by pain, anxiety, cognitive impairment Principle-agent theory – Physician contracts to act as patient’s agent – Patients interests are advanced when the physician (clinician) recommends services with evidence of benefit 17
  17. 17. 18
  18. 18. Decision-making at the Point of Care  Patients seek physicians to address their health concerns – And relieve their symptoms/distress  Each patient encounter generates numerous decisions  Physicians make these decisions in the face of extensive and conflicting relevant evidence – Many studies, few answers  All diagnostic tests are imperfect – Inherent risk of over-diagnosis and under-diagnosis – Multiple sequential tests do not help 19
  19. 19. Clinician incentives can bias decisions Clinician beliefs about their professional role Assessment of “prior probability” Interpretation of clinical findings (eg over-diagnosis) Recollection of clinical research evidence – 23,000 clinical trials published in English each year Maslow’s Hammer – reputational bias – pseudo-consensus Facilitating Adherence
  20. 20. Too Little? Too Much? Primary Care Physician Views  95%- believe physicians vary in what they do for identical patients  42%- patients (in their practice) receive too much care  6%- patients receive too little care  Most important factors for aggressive practice – Malpractice concerns - 76% – Clinical performance measures- 52% – Inadequate time to spend with patients-40% – Financial incentives • 62% subspecialty diagnostic testing could be reduced • 39% primary care diagnostic testing could be reducedB E Sirovich, S Woloshin, L Schwartz, Arch Intern Med. 2011;171(17):1582-1585
  21. 21. FFS and Point of Care Decision-making  FFS offers straightforward method to encourage delivery of services at the point of care – Patients have greater trust under FFS payment  FFS may not provide consistent incentives to promote evidence- based practice – Poor calibration of fees- eg high margins for services of limited effectiveness  Potential impact of FFS imbalance on point of care decisions – Over or under-testing – Over or under diagnosis – Over or under treatment 22
  22. 22. Imaging for Low Back Pain* High margin for imaging studies for back pain creates incentives for physician/clinician to … – Promote increased patient awareness of medical services for the problem – Increase patient access for evaluation – Perceive higher likelihood of conditions that require testing – Provide services to help patients adhere to testing recommendation If imaging study is an efficient means of diagnosis candidates for a high margin treatment – then additional incentives for physician/clinician to … – Diagnose the condition that warrants the high margin treatment – Provide services to help patients adhere to testing recommendation * Overused service identified by “Choosing Wisely” program 23
  23. 23. Antibiotic prescribing in Sinus infection  No direct FFS incentive of ABX RX (in US)  FFS incentive to recommend an approach that satisfies patient expectations – ABX plausibly effective in addressing the likely diagnosis – Patients prior belief regarding ABX efficacy – Patient desire to avoid missed work/school – Patient preferences and shared decision-making  Current FFS provides inadequate incentive to educate patients regarding risks and benefits  Patient satisfaction may not be enhanced by efforts to discourage antibiotic prescribing 24
  24. 24. Treatment “under-management” for GERD  GERD Rx “should be titrated to the lowest effective dose needed to achieve therapeutic goals”  Evidence-based care requires: – physician must contact asymptomatic patients on chronic therapy for GERD, – reduce medication dose as appropriate, – Follow-up on symptom response and further adjust medication  Not easily rewarded via FFS  May be viewed as unwelcome distraction by asymptomatic patients 25
  25. 25. Payment reform options: potential impacton evidence-based care  Revised FFS  FFS + P4Q  Episode-based payment  Global payment (capitation) 26
  26. 26. Revised FFS Advantages- – Many current fees not reflective of physician work (some over-valued, some under-valued) – If margins for physician services are high, practices will increase use – Increased payments can address underuse of highly effective services Disadvantages – Reducing payments for overused services may not consistently reduce demand • Inertia, prior beliefs • “physician induced demand” • Risks of payment reductions below actual cost • Many overused services not driven by FFS incentives (antibiotic use) • Under-management of chronic illness not easily addressed by encounter- based FFS – Challenges in adjusting ffs payments based on evidence of effectiveness • Services often proven effective for one patient subgroup- benefits unclear for others • Ever-changing clinical research evidence 27
  27. 27. FFS w/ P4Q  Advantages- – Monitor/reward better chronic care management (eg GERD management) – Monitor/reward appropriate use of test or treatments (e.g. back imaging, antibiotic use)  Disadvantages – Focus P4Q on high priority services • physicians make numerous decisions per encounter, 1000s of decisions per day – Rectify conflicting P4Q signals from multiple payers – Assuring salience to real-world decision-making • Attribution to the correct clinician decision-maker • Patient risk adjustment, benchmarking – Quality measures ≠ evidence-based practice 28
  28. 28. 23,000 clinical trials/yr = Enough Evidence? Robert Califf, IOM Meeting, 12 December 2008. Less than 20% of AHA/ACC heart disease management recommendations are based on a high level of evidence and over 40% are based on the lowest level of evidence: Level A evidence (multiple populations and risk strata) to Level C (very limited population risk strata). The proportion of recommendations with high evidence levels has not increased over time.
  29. 29. Heterogeneity of Treatment Effect Diagram by J. Meddings (Vijan & Hayward, Ann Intern Med 1997)
  30. 30. Stringent Dichotomous MeasuresDon’t target patients most likely to benefit – Ignore the heterogeneity of patient risk factorsDon’t help providers do the “right” thing – Blunt instruments with little or no clinical nuanceDon’t take into account patient preferences – Often mandate care not wanted by well-informed patientsCould result in unintended consequences – Polypharmacy, hypoglycemia, worse outcomes, wasteful spending R Hayward, 2012
  31. 31. FFS w/ P4QOverused +/-testUnderused √testOver DX +/-Under DX √Overused +/-RxUnderused √RxUnder- +/-mangd Rx 32
  32. 32. Episode-based payment  Advantages- – Single payment for all services needed during an episode of illness – Removes “piecework” incentive of FFS – Incentive for constraining volume of services during an episode of illness – Over testing example- • Physician discretion to make “evidence-based” use of imaging for diagnosis and management of back pain • Testing represents cost, not additional profit 33
  33. 33. Who to Give the Episode Payment To? Practice environment and clinical decision-making Collecting Data on Physicians and their Practices, AHRQ Report, 2012
  34. 34. Practice environment and clinical decision-making Patients  Physicians – Age, gender, race/ethni – Personal characteristics city – Clinical training – Health concerns and – Current experience/ chronic conditions expertise – Financial access to – Professional attitudes care • Attitudes toward – Education level, health evidence, literacy • Attitudes towrd shared – Patient decision-making, etc preferences, expectati ons, values
  35. 35. Practice environment and clinical decision-making  Point of Care  Practice Organization – Clinical focus – Practice organization size • Inpatient, and specialty mix outpatient, ASC – Practice ownership – Clinical colleagues • Physician partnership – Clinical workload • Private hospital – Resources (support • Health plan staff, examination • Academic medical center rooms, patient – Practice governance and educators) leadership – HIT – Organizational culture – Decision support – Sources of revenue, payer – Care management mix – Availability of DX/RX – Physician compensation technology and incentives
  36. 36. HIT at the Point of Care  How frequently do you use a computerized or electronic system to perform the following tasks at this practice location? – Order laboratory tests – Obtain clinical decision support – Generate a list of patients overdue for tests or preventive care – Access standard order sets for a particular condition or procedure – Provide reminders for guideline-based interventions or screening tests – Electronically exchange patient clinical information with any other clinicians outside your practice organization or hospital 37
  37. 37. Practice environment and clinical decision-making Networks and  Market Environment, Affiliations – Provider market – Shared resources with concentration other practice – Commercial payer organization environment (e.g., HIT, billing, equip – Malpractice environment ment, space) – Community resources – Formal relationships with broader networks – Urban/rural of providers (e.g., IPAs, PHOs, ACO s, etc.)
  38. 38. “Physicians don’t just work for money” Ability to do good- accessing/managing resources related to what they care about (e.g. innovative clinical programs, interesting clinical problems or procedures) Ability to do important work- accessing/managing high quality clinical program resources (e.g. nurses, physicians assistants, technicians, equipment, etc) Ability to do what they want- managing personal time, personal administrative support, etc
  39. 39. Changing the employed clinician’s “margin”Compensation Work environment % income at risk  Workload – Work assignments Performance – call measures – “hassles” – “Productivity measures”- eg billing  Support staff /space – Quality metrics – Patient satisfaction  Ease/difficulty obtaining – Organizational financial tests, services performance  Recruitment /retention “Perks” – Professional  Professional culture development – leadership 40
  40. 40. Who to Give the Episode Payment To?  Most physicians participating in episode-based payment will be compensated by a larger entity receiving the bundled payment  The incentives presented to this larger entity will be translated thru internal management to influence clinical decisions at the point of care. 41
  41. 41. Physician Compensation Strategies and Intensity of Care  Highly capitated practice environments had lower intensity of care for episodes of care  Productivity payments had the highest spending  True for practice owners  and for employed physiciansLandon, et al. The Relationship between Physician Compensation Strategies and the Intensity ofCare Delivered to Medicare Beneficiaries. HSR July 2011
  42. 42. Episode-based payment  Disadvantages – Episode-based payments may discourage evidence- based testing and treatment during an episode of illness • PFTs in asthma • Drug management in GERD – Episode-based payments tied to diagnosis of illnesses • Potential incentive for over-testing to find episodes • Potential incentive for over-diagnosis from test results – Episode-based payments often tied to high cost services (like surgical procedures) • Potential incentives for over-Rx  P4Q can help – Same limitations as FFS 43
  43. 43. Episode- based paymentOverused +/- the role of episode-basedtest payment reform in over-usedUnderused +/- tests or treatments is highlytest contingent on how decisions about these services areOver DX +/- incorporated into the definition ofUnder DX √ episodes of care.Overused +/-RxUnderused +/-RxUnder- +/-mangd Rx 44
  44. 44. Global payment (Capitation)  Advantages- – Single payment for all services needed by a patient during a year – Removes “piecework” incentive of FFS – Incentive for constraining volume of low- value services for patients – Incentives for providing services that are effective in averting unnecessary spending on preventable illnesses or illness complications  Who to Give the Money to? – Accountable care organizations 45
  45. 45. Incentives for Care of Low Back Pain  incentive to reduce patient access to expensive clinical services  Incentive for clinician to perceive a lower likelihood of conditions that require costly testing or treatment  Incentive for convincing patients of the risks of additional imaging studies or interventions  Incentives for promoting adherence to low cost options  Incentives for discouraging adherence to costly interventions like advanced imaging or surgery 46
  46. 46. Global payment Disadvantages – Capitation may encourage reduced access and under- diagnosis – Capitation may discourage evidence-based testing and treatment • PFTs in asthma • Drug management in GERD P4Q can help – Daunting limitations • How to properly measure and reward myriad decisions at the point of care 47
  47. 47. Global paymentOverused √ •For some chronic conditions thetest intermediary receiving the capitated payment can realize near-term financialUnderused +/- gains through improved chronic diseasetest management.Over DX √ •In many patients more evidence- based point of care decisions confer near termUnder DX +/- costs, with savings realized only many years hence, or not at allOverused √RxUnderused +/-RxUnder- +/-mangd Rx 48
  48. 48. Revised FFS w/ P4Q Episode- Global FFS based payment paymentOverused +/- +/- +/- √testUnderused √ √ +/- +/-testOver DX +/- +/- √Under DX √ √ √ +/-Overused +/- +/- +/- √RxUnderused √ √ +/- +/-RxUnder- +/- +/- +/-mangd Rx 49
  49. 49. Policy Goals for Payment Reform Promote evidence-based decision-making at the point of care – Patients seek clinicians they can trust to recommend “what is best” – Professional societies and policy makers want clinicians to recommend evidence-based services – Incentives that do not consistently reward evidence-based care will prove unacceptable to both patients and clinicians Other purposes for broader payment reform – Correcting clinician specialty imbalances – Addressing care fragmentation – Enhancing the role of primary care clinicians – Promoting new modes for addressing patient concerns 50
  50. 50. Incentive Reform to Promote Evidence-based Care  There are many mechanisms for paying physicians; some are good and some are bad.  The three worst are…  fee for service, capitation, and salary. – James Robinson
  51. 51. Incentive Reform to Promote Evidence-based Care  Recalibrate productivity measures to recognize physician costs (margin) at the point of care  Monitor patterns of care relative to highly effective services – Overused and underused tests – Over- and under-diagnosis – Overused and underused treatments – Under management of chronic conditions  Choosing Wisely Program – One place to start 52
  52. 52. For under-used, highly effective, tests or treatments  Address clinical issues – Knowledge, diagnostic skills – Conflicting interpretations/ professional standards – Easy access to knowledge resources and decision support  Incentive reform – Re-evaluate for mis-calibrated physician costs – If productivity measures look appropriate consider • Compensation plan – Increased FFS payment (to jumpstart increased use for highly effective services) – P4Q incentives to increase awareness of appropriate use • Work environment – Workload, Support staff , Ease of ordering/obtaining – Professional culture – ??Reminders (recent surveys show reminder burden) 53
  53. 53. For over-used in-effective, tests or treatments  Address clinical issues  Incentive reform – Re-evaluate for mis-calibrated physician costs – If productivity measures look appropriate consider • Compensation plan – Eliminate production incentive for this service – P4Q incentives to increase awareness of appropriate use – Production incentives/targets based on expected utilization • Work environment – Ease of ordering/obtaining – Referral process – Workload, Support staff – Professional culture 54
  54. 54. Policy Goals for Payment Reform Promote evidence-based decision-making at the point of care – Patients seek clinicians they can trust to recommend “what is best” – Professional societies and policy makers want clinicians to recommend evidence-based services – Incentives that do not consistently reward evidence-based care will prove unacceptable to both patients and clinicians Other purposes for broader payment reform – Correcting clinician specialty imbalances – Addressing care fragmentation – Enhancing the role of primary care clinicians – Promoting new modes for addressing patient concerns 55
  55. 55. Promoting evidence based care to address rising health care costs – “…little rigorous evidence is available about which treatments work best for which patients” Solution: CER/PCOR – And”…financial incentives … tend to encourage the adoption of more expensive treatments and procedures, even if evidence of their relative effectiveness is limited” Solution: Provider payment reform Orszag and Ellis, NEJM, Nov 2007

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