CONTAINING MEDICARE COSTS BY IMPLEMENTING BEST PRACTICE GUIDELINES

When physicians are unsure of the best course of care, many tend to increase treatment under the assumption that more care creates better outcomes. However, in the Dartmouth Atlas Project’s most recent report, researchers found that more intensive care does not always lead to better outcomes. Indeed, mortality is often higher in areas in which more resources are used, with variations in severity of illness only accounting for only a small fraction of the observed variation in mortality.

Although research has been done on evidence-based practices, few physicians have accepted and implemented published guidelines. To make this research more readily available, best-practice agents will work under the auspices of the Center for Medicare and Medicaid Services (CMS) to disseminate treatment guidelines and criteria, as published by organizations such as the Agency for Healthcare Research and Quality (AHRQ) and the American College of Physicians (ACP). Best practice agents will employ tactics similar to those of pharmaceutical representatives. They will cultivate relationships with physicians, dispel myths, and help to establish incentives for physicians who implement the guidelines. The intent will be to change physicians’ behavior so as to lower costs and improve care.

KEY FACTS
• Without guidelines for best treatment practices, physicians often dispense medicine under the assumption that more care equals better care.
• Various measurements (including patient satisfaction, health outcomes, quality of communication, and continuity of care) indicate that greater use of resources is not always associated with better care.
• There is tremendous variation in the average amount of money spent per patient with a chronic disease in the last two years of life, ranging from $59,379 in New Jersey to $32,523 in North Dakota. Yet most of this variation cannot be explained by differences in price, disease prevalence, or patient preferences.

TALKING POINTS
• One barrier to eliminating unnecessary treatments is physicians’ lack of knowledge of and adherence to scientifically proven treatment guidelines.
• Pharmaceutical representatives have been extremely effective in bringing information to physicians and altering their behavior. Best-practice representatives will model their efforts off pharmaceutical representatives’ tactics.

HISTORY
Variations of this idea have been tried in Medicare demonstration projects, one being the Physician Group Practice (PGP) project. This was CMS’s first physician pay-for-performance initiative. One measure of performance was improvements in quality of care, and one participating physician group’s strategy for improvement was to implement evidence-based practice models. This group has disseminated information on best-practice models through internal guidebooks, nurse educators, and management and peer reviews. Though preliminary results have been promising, a final report has not been released.

ANALYSIS
If best practice representatives are able to successfully change behavior, results could be dramatic. Treatment uniformity could eliminate ineffective procedures and reduce overall costs. Private insurance companies may seek to implement this type of program as well.

However, there will be challenges to implementation. Physicians may be reluctant to adhere to the advice of uncertified medical professionals and resistant to oblige by clinical standards. They may feel that guidelines will diminish their autonomy. While these concerns may be warranted, physicians can be assured that best practice representative will be highly trained and specialized. Additionally, CMS will take into account the vicissitudes of medicine by allowing physicians flexibility in adhering to guidelines.

NEXT STEPS
CMS should wait for the results of the PGP project before proceeding, as they may offer useful insights and directions. After analyzing the PGP results, CMS should begin identifying and training best-practice representatives. They should be individuals who have a medical background or are seeking to enter the field. Representatives should choose a condition or area of study and begin an intensive training course, similar to the training of pharmaceutical representatives; the training and work method of best practice representatives should be modeled off that of pharmaceutical representatives.

Paying for this program may be expensive, but possible funding streams are available and there may be some offsets, such as money saved through eliminating unnecessary treatments. Another possibility would be to introduce this program under a larger health care reform package financed through the expiration of the Bush tax cuts.

SOURCES

Department of Health and Human Services. “Physician Group Practice Demonstration: First Evaluation Report.” 2006. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/PGP_Final_Congress....

Garber, Alan. “Evidence-Based Guidelines As a Foundation For Performance Incentives.” Health Affairs Policy Journal, no. 1, 2005. http://content.healthaffairs.org/cgi/content/full/24/1/174?ijkey=khuayL.....

Lind, Keith, & Williams, Jackson. Future of Medicare: Report on Expert Views. AARP Public Policy Institute, May 2007.

Manchanda, Puneet & Honka, Elisabeth. “The Effects and Role of Direct-to- Physician Marketing in the Pharmaceutical Industry:

An Integrative Approach.” Yale Journal of Health Policy, Law, and Ethics, V:2, 2005. http://wwwpersonal.umich.edu/~pmanchan/Advertising_files/Manchanda_Honka....

Wennberg, John; Fisher, Elliot; Goodman, David; & Skinner, Jonathan. “Tracking the Care of Patients with Severe Chronic Illness.” The Dartmouth Atlas of Health Care 2008. http://www.dartmouthat las.org/atlases/2008_Chronic_Care_Atlas.pdf.

United States Government Accountability Office. End of Life Care: Key Components Provided by Programs in Four States. December 2007. http://www.gao.gov/new.items/d0866.pdf.