Posts tagged ‘CER’

Evidence-based radiology — a concept on the cusp


For some years now, payers, academics and clinical practitioners have had concerns about the justifications for clinical practice patterns.   The need for evidence-based practice ranges from formulary design to clinical care to radiology.

“Medical practice is largely based on clinical anecdotes, uncontrolled investigations and expert opinion. The demand for scientific evaluation to guide patient care is increasing because financial resources are limited and because practice based on such influences may be inappropriate. In radiology, the situation is especially problematic…. Few radiology programs address and encourage critical thinking skills.” (Source: Hillman BJ, Noninterpretive skills for radiology residents. Critical thinking: deciding whether to incorporate the recommendations of radiology publications and presentations into practice. AJR Am J Roentgenol 2000; 174 (4):943-946.)

For example,  when clinicians, such as radiologists, health plan administrators, and others try to decide between imaging and interventional options, they may find that textbooks are out of date, guidelines are not specific enough and there are conflicting or apparently unreliable reports in the literature. Expert opinions and policies vary and even the definition of ‘evidence’ is unclear.

Some experts recommend using the ‘consensus of experts’ approach.  However, the reliability and reproducibility of this type of evidence is questionable.  Others recommend the use of guidelines that are based on expert appraisal of the literature.  These are roughly equivalent to a consultation with experts but may not answer our specific question well, be based on strong evidence or take into account new developments and local circumstances.  However, when clinicians and health plan administrators go to the literature, the first problem encountered is the volume of literature being published and, perhaps, a lack of training in how to separate the good studies from the weak ones.  Another problem is determining whether specific clinical decisions and medical policies should be based on the general consensus illustrated by the evidence or following a minority opinion that better applies to a specific situation or sub-group of patients.

One of the issues facing healthcare manufacturers is how to best support clinicians and administrators as they address these challenges.  For healthcare manufacturers, the key questions are 1) What type of data will my customers find most compelling?  2) How will that data best support my marketing efforts and support appropriate adoption of my product? 3) How can I develop the data most cost effectively?  Is a retrospective study or an observational study sufficient?  Is a costly prospective study with a randomized design necessary?  4) What return will I realize from the data I develop?

The first step for healthcare manufactures is to realize the data are necessary.  As comparative effectiveness research becomes more prevalent and clinical decisions are increasingly scrutinized, data is all that clinicians and administrators will find relevant and compelling. 

The next step is to develop an evidence plan early in the product development process.  To the extent possible, the time to develop such data is when drugs are going through clinical trials or diagnostic assays and imaging equipment and applications are under development.   Developing data after FDA approval and product launch could burn the limited commercialization time available before a competitor arrives or patent protection expires.

The evidence plan should be based on the expected return on investment.  If less-costly retrospective and observational studies will drive adoption, though perhaps not optimally, they might optimize ROI.  Potential market blockbusters might warrant costly prospective, multi-center studies that support a lasting and profitable competitive advantage.

The design of specific studies within the evidence plan should be based on the intended audience.  Payers (eg, health plans and hospital administrators) are looking for value.  That is the expected improvement in quality of care, based on specific and measurable outcomes, divided by the impact on cost.  Cost includes that of the drug, device or imaging application as well as any cost offsets (eg, reduction in hospitalizations) directly due to the product.  Providers are more focused on improvements in clinical care and outcomes and, to a lesser degree, cost impact. 

As today’s discussion begins to illustrate, the development of an evidence plan is a complex undertaking that should be well thought out.  Today’s environment and its emphasis on comparative effectiveness, cost management and access to appropriate therapies and procedures makes the development of the evidence plan more critical than ever before.

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July 23, 2010 at 12:49 PM Leave a comment

Compensation and the Patient-Centered Medical Home


Compensation for a PCMH team must achieve the following outcomes: 1) Reward improvements in outcome, 2) Drive decreases in the utilization of healthcare resources; 3) Encourage cooperation among team members.  Compensation structure should be simple enough for everyone to easily understand, measure their performance and calculate their expected compensation.  In other words, compensation should be evidence- and value-based rather than based on piecemeal work.

Of course, this is easier said than done.  Compensation is the most difficult issue associated with the patient-centered medical home (PCMH).  Understandably, no one wants their income to decrease and everyone wants to be compensated for the work they do (or don’t do).  Primary care physicians want compensation for coordinating the PCMH provider team.  Specialists and institutional providers, such as hospitals, don’t want to see a drop in their current income levels, even if their workload decreases. 

Compensation systems should be based on improved outcomes, both in the short term and the long term.   In many instances, short-term markers will be substituted for more appropriate long-term outcomes.  For example, measuring improvements in HbA1c scores for diabetes patients is more practical than measuring reductions in cardiovascular events and other co-morbidities.

As well, the PCMH should share the cost savings that insurers realize, without double-counting the cost savings associated with improved outcomes.  If the PCMH can realize the same outcomes with a comparable level of risk but fewer diagnostic exams or specialist referrals, the PCMH team should share those savings.  Sharing the cost savings will encourage providers to reduce the services they provide as the impact on their income will be softened.

Measuring the risk associated with reduced levels of care is as important as measuring short-term improvements in outcomes.  For comparison, many US corporations focus on short-term results as that drives their bonuses.  However, the long-term risks rise.  For example, Wall Street executives recognized significant profitability from derivatives and other risky trading and money management strategies in the years leading up to 2008 and the Great Recession.  We must avoid similar behavior with our healthcare status.

Developing a value- and evidence-based system that provides compensation based on improved outcomes, cost savings and acceptable levels of risk is a complex, time-consuming and costly endeavor.  It is predicated on the widespread implementation of EHR, the funding of comparative effectiveness research, and gaining consensus on outcomes, risk and cost-savings metrics and their measurement.  Therefore, compensation systems that enhance the effectiveness of PCMH will be phased in over time and increase in scope, complexity and benefit to the healthcare system over time.

As hinted at above, effective compensation systems requires sharing of rewards among the PCMH team.  That argues for further integration of providers to facilitate such sharing.  We’ll explore that issue next week. 

Take care and have a fun holiday weekend.

May 28, 2010 at 6:47 PM Leave a comment


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