21 September 2018
Dear Interested Readers,
Overuse, Misuse, and Underuse: Hallmarks of Suboptimal Practice and a Barrier To a Better Future
Healthcare will definitely be an important, if not the top issue in the November midterm elections. Earlier this week one of the healthcare writers for the New York Times, Margot Sanger-Katz, pointed out that the issue of preexisting conditions is central to several of the Senate elections and could turn out to be an advantage for incumbent Democratic senators, like Joe Manchin in West Virginia and Heidi Heitkamp in North Dakota who are running against strong Republican opponents in states where President Trump won with a large majority in 2016.
In the article Sanger-Katz reminds us that West Virginia has benefited as much or more than any other state from the passage of the Affordable Care Act and according to estimates from the Kaiser Foundation, it has more citizens with a preexisting condition than any other state. As I pointed out in a recent posting, the current question about the constitutionality of the ACA, now that there is no mandate, is not an issue that will be settled in the Congress. It will be determined in the Supreme Court. The stage is set to answer that question in a damaging way when Brett Kavanaugh or any other conservative justice that President Trump chooses to appoint is finally confirmed and seated on the Supreme Court bench.
Americans with preexisting conditions will remain vulnerable until we have a House and Senate that are willing to give us ACA 2.0 and a president that would sign their bill. The earliest moment that could happen will be after Inauguration Day in 2021. A fundamental underlying question to the whole scary story is why voters in states like West Virginia, Arkansas, Louisiana, North Dakota, and Kentucky consistently vote against their own best interests on healthcare and other issues of the general economy. If you Google the question, you can spend the rest of the day reading a variety of opinions. The fact is that they have. The question related to this election and the protection of insurability without penalty for a preexisting condition is whether they will continue to do so. I will cross my fingers, hope for change, and cast my vote in November.
In time I am confident that our society will demand protection and decide once and for all that we all will eventually have a preexisting condition, and that we all deserve coverage that is affordable before and after we are sick. The issues are really when will that consensus emerge, how much damage might be done to our system of care, and how much suffering will occur for those who have been identified as having preexisting conditions between now and that moment of national enlightenment and consensus when healthcare becomes a universal entitlement.
There is an issue of equal, if not greater, importance to the future of healthcare than what happens to coverage for preexisting conditions that I am sure will not be debated in the campaign this fall, or at anytime in the foreseeable future. How we practice is the issue that is the greatest contributor to the excessive cost of care, and in truth it is the one issue over which clinicians of all stripes have the greatest control. Historically, practice has been a very individual endeavor. Most of us value “practice autonomy” the way an NRA member values the Second Amendment right to bear arms. The result has been that “practice variation” is an accepted “right” of clinicians and the documented source of enormous costs, care inequalities, and diminished quality. Complicating the ethical issues of professional autonomy are the issues of patient autonomy. How all the issues of autonomy collide and coexist in an era when we are searching for sustainable pathways toward universal healthcare access and the Triple Aim is beyond the scope of this short posting. But the outcomes of “autonomy” exercised without consideration of the overall consequences is worth our focus for a moment. In a 2016 Johns Hopkins Medicine overview of medical errors as the third leading cause of death in America we read:
Unwarranted variation is endemic in health care. Developing consensus protocols that streamline the delivery of medicine and reduce variability can improve quality and lower costs in health care.
I have enjoyed the joke about “group practice” being defined as doctors sharing a parking lot. We all have heard about “practicing together alone.” In a posting earlier this week I fondly described my experiences and sense of professional fulfillment as part of a team. As important as team based care is as a hedge against personal burnout and as a path to professional fulfillment, reduction in practice variation is even more important to improving the cost and safety of the care we provide.
At the core of most of the personal, institutional, and national concerns about healthcare is not its quality or access; it is the growing cost of care. That fact may not be the way it should be, but it is hard to argue that collectively we make any component of healthcare including quality, safety or access, more of a concern than cost. Cost is primarily driven by how we think and how we apply our thoughts to how we practice. It’s a long argument, and many will disagree, but it is my contention that we will never have the healthcare we need or would like to have until clinicians work together to reduce practice variation and address the waste and cost that is generated by “overuse, misuse, and underuse” of medical resources.
I commented in the piece on team based care that I did not hear references to “medical homes” as often these days as I did a few years ago. To that observation I would say that compared to the conversations that culminated in the “Choosing Wisely” movement of a few years ago, I don’t hear or see discussions about practice variation, resource utilization, or the importance of attention to “overuse, misuse, and underuse” that I was hearing just a few years ago.
I will risk offending more clinicians by saying that in the practices I follow, in the conversations that I have with clinicians in meetings, in the contacts with the healthcare systems that I observe through the eyes and experience of family and friends, there seems to be a decline, certainly not an improvement, in “critical thinking.” Perhaps the decline is another manifestation of burnout. It could be the result of over attention to compliance with standards. It could be derivative of defensive medical practice as a hedge against malpractice. Perhaps it is derivative of the desire to give patients what they want to improve patient satisfaction with no consideration to the likelihood of benefit. It is probably derivative of all these things and others. I wish that I could say that the question in my mind is less what is the cause than what is the solution, but solutions without attention to the origin of the problems they address rarely work.
There is an excellent article by Volpe, Lowenstein, and Asche that gives an overview of the origins and barriers of the problems of overutilization that the Choosing Wisely campaign attempts to address. It also includes comments about the effectiveness of copays in reducing unnecessary utilization. It is worth your attention because it realistically describes many of the barriers to better utilization.
Many of us are aware of the metaphor that healthcare economist and Harvard Professor Michael Chernow has used to describe the frustration of clinicians and healthcare management in an era when they have some patients who have fee for service coverage and others that are covered by value based contracts. Chernow says that managing in the current environment is like standing with one foot on a sinking dock and the other in a “tippy” canoe. Whatever metaphor describing the moment speaks to you, many organizations and clinicians are struggling with the ongoing challenges that face a healthcare system that is currently recording losses and realistically is expecting more losses in the near future because they are in the transition from fee for service practice to value based reimbursement. To that stress add the reality that no matter what the form of payment, the income from the care of publicly funded patients is going down as the demands go up.
Many organizations describe the situation as “a poor payer mix.” They are also struggling with the imperatives of adjusting to the realities of MACRA, anticipated declines in public funding of Medicare and Medicaid, more bad debt as the ACA is pushed to the brink, and the vagaries of projected finance in the ACO era. In the untenable reality of deteriorating finance they are reminded of Sister Irene Krause’s famous law: No margin, no mission. It sometimes occurs to them that a good way to mitigate their stress would be to push utilization in their existing traditional fee for service commercial contracts, and divert the patients who are covered by the “value based reimbursement” contracts where they had risk to “other programs” of more conservative care.
I heard well meaning managers in the organization that I led propose ideas along the line of “make the money where you can.” Cost shifting is an established concept in healthcare. The idea is basically unethical and almost impossible to implement since most clinicians I know are not that familiar or focused on the finance behind the individual patients that they see. They usually practice in only one consistent way with all patients. The strategy leads to excessive utilization and the delay of the organization’s transformation to an ability to accept risk, improve quality and satisfaction, and reduce waste.
I see a lot of physician compensation proposals and hear about more. I also see and think a lot about the management structures and budgeting processes of group practices, hospitals, and health systems. Let me warn you that if your compensation program is heavily weighted toward RVU production, and most are, and if you are organized along service lines and not along pathways of care, and localities of practice, your organization is probably contributing to the problem of overuse, misuse, and underuse in the delivery of care.
Overuse and misuse generally are understood as doing things that are not needed and do not add value, like inappropriate testing or doing something that is not indicated like arthroscopic surgery on a patient with osteoarthritis. Underuse is something that is less generally understood. It is not developing programs of preventative care, appropriate health screening, chronic disease management, self care, home care, and attention to the issues of healthcare disparities. Correcting chronic underuse of appropriate care is perhaps more difficult or less exciting than attacking overuse and misuse, and its importance is often overlooked or discounted.
In Lean thinking and practice one useful exercise is to ask and answer “five whys.” If I do five whys with the issues that I have discussed above, I have a hard time making it an orderly process, but I do get to a collection of underlying issues that contribute to our current cost concerns. Some concerns, like the soaring cost of medications, the introduction of new expensive medications, and the need to adopt new and beneficial, though expensive, technologies are partially beyond our control. As individuals within an organization some of us may have input into issues like the development of efficient programs of care, and the business partners we use, if we get involved. But all of us have an opportunity to make a small difference that can collectively add up to a large difference, if we apply critical thinking to each patient encounter.
Years ago Dr. Ed Murphy, who was then the CEO of Carilion Healthcare in Roanoke, Virginia, convinced me that a major factor in the root causes for the rapidly rising cost of care was what clinicians ordered and the critical thinking that they applied to practice. The questions we need to ask as we move to that moment in any encounter where decisions are made and orders are placed are simple, but often never asked. Here is an incomplete list:
- What matters to the patient, and have we even had that conversation?
- What will this cost the patient in time, risk, and money?
- What are my biases?
- Am I placing this order defensively, or just because I do not have the time to think, or the energy to have a better conversation with the patient?
- In this clinical situation what is the “best practice?
- Is there a compelling need to do something now?
- What will we do next depending on the outcome of the procedure or result of this intervention/test/ medication?
When we talk about positioning clinicians to “work at the top of their licenses,” I hope that we are talking about structuring the practice or the environment of care in a way that supports critical thinking in practice. As practitioners, I hope that we realize it is an autonomous act of professionalism to align yourself with a best practice. I have always felt that the most significant way we can express our professional autonomy is in the ways we use our professional skill, compassion, and interpersonal skills to build a relationship with the patient. I like the concept of a “therapeutic contract.” It takes a personal motivation and commitment to serve the patient to build a relationship of trust that supports helping patients realize “patient autonomy” within the context of what is the most effective approach to their problem that we know. There are almost always choices. Game theory suggests that making the best choice, even if it is difficult or perhaps even expensive, leads to the most efficient outcome over a series of choices. I am not arguing for a denial of care, or advocating “cheap” care. I am advocating a critical process that searches for the right care, and not the choice of care or the use of compensation programs that are intent on maximizing revenue.
Going back to the strategic suggestion to focus on productivity which is a euphemism for maximizing revenue through a focus on volume for those patients with generous payers, and thinking about “other things” for those whose coverage is population based, I can understand how the concept evolved. It is a stark expression of our current practice reflexes when we are “thinking” fast. There are times in the delivery of care when we must “think fast” and act on reflex. That is not the case most of the time. Thinking about managing patients in the context of the revenue they might produce is more than an expression of a lack of equity for the patient whose care is publicly financed or who is covered by a risk contract. I fear as much or more for the future of the patient who is perceived as representing the “income opportunity.” Thinking based on misdirected concepts of productivity in an environment where doing more provides short term financial benefit is one of the root causes of the problems we are now trying to solve. We won’t get to a better place until we are willing to focus on supporting clinicians in a way that encourages the critical thinking and relationships with patients that reduce overuse, misuse, and underuse.
Surprise Observations: Birds and Squirrels
I like birds. I love the loons and mergansers on our lake. I am thrilled when I see an eagle perched in a tall pine on a nearby shore. I love feeding birds. My bird feeders consume about ten forty pound sacks of black oil sunflower seeds and six or eight dozen suet cakes a year. I have a serious bird feeding habit.
We see lots of chickadees, two kinds of nuthatches, lots of yellow finches, titmice, juncos, hairy woodpeckers, downy woodpeckers, blue jays, and hummingbirds at our feeders. I don’t understand why cardinals seem in short supply. Rare sightings include rose breasted grosbeaks, and yellow bellied sapsuckers. I don’t much notice the robins and doves since I never see them near the feeders.
Once or twice a year, usually in the spring, I wake up to discover that overnight a bear had come by for a snack. They destroy the feeders like they were cracking the shell on a peanut. I learned the hard way to take in the feeders overnight in the early spring which fixed the bear problem. Years ago a young bear came by midday in the middle of July. He did not understand the rules.
There are always squirrels hanging from my bird feeders. But this year there are more squirrels than ever. There are so many that they get in line and wait their turn. I hear that the population of squirrels has exploded because last year there was a bumper crop of acorns. I have no scientific numbers except I have bought a lot more sunflower seed this summer than ever before. The squirrels can empty two large feeders in less than three days. It would take the birds a couple of weeks if there were no squirrels to help them.
There are reports of hundreds of dead squirrels on the highways in New Hampshire. It seems to be worse near on and off ramps, and anywhere there are Jersey barriers. The squirrels are all the talk on our local TV stations and in our newspapers. I have found evidence that the same problem exists in New York and Maine.
The final fun fact about squirrels this summer is that they are taking to the water. I was a little skeptical of the story about swimming squirrels until last weekend. My wife and I were out with our neighbors on their boat enjoying a bonus summer weekend when we saw something swimming across a narrow place in the lake. You guessed it. It was a big grey squirrel. When he got to the otherside he climbed up on a big rock and shook himself off like a dog before he scampered off into the underbrush.
The biggest thrill of last weekend is the subject of this week’s header. I was headed out the door on my way to the 10 o’clock church service when my wife exclaimed, “Look out the window at the front yard!” There were five beautiful birds that were new to our yard. They seemed to be searching for grubs or worms. I quickly got the camera to record their visit and then later used Roger Tory Peterson’s Field Guide to Eastern Birds to find out that our visitors were Northern Yellow-shafted Flickers or if you prefer, common flickers.
It seems unfair to call such a magnificent bird “common.” The bird in the picture is a guy. The male flicker has a black “mustache” that extends down from the edge of his mouth. Note the red stripe on the back of his head and the black “shield” on his breast. The yellow shafts on the wings are only visible when they spread their wings in flight or when they are doing a mating dance.
The weekend in New England is predicted to be a little on the cool side. That is no reason to stay inside and watch the Patriots or the Red Sox. The Red Sox are resting up for the playoffs and the Patriots better not lose to Detroit. If you must watch either of them, set the DVR to record the game for you to watch after sunset, and get outside to see what’s happening with the fauna in your neighborhood.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
