Have you ever read about the waste in our healthcare system and wondered why insurers cover so many apparently wasteful services in the first place? You’d think they could just refuse to cover those things and save themselves and the entire system a lot of money.
In Wendy K. Mariner’s Rationing Health Care and the Need for Credible Scarcity: Why Americans Can’t Say No, published in Health Law and Ethics in 1995, she discusses this issue. Even though the article is from 1995, I think her insights still apply.
“When the media report that a woman is dying of advanced breast cancer and her insurer will not pay for high dose chemotherapy and autologous bone marrow transplantation because it considers the procedure experimental or unsuitable for her, the insurer is widely viewed as depriving the woman of a chance at life to which she is entitled. Insurers may argue that the insurance policy expressly excludes such procedures and that the woman agreed to its limits. Such arguments, even when correct, do little to assuage feelings that the insurer is depriving people of care to which they should be entitled. This feeling is exacerbated by the suspicion that the insurer could pay for the treatment if it chose, that it has enough money to buy services that are readily available. Thus, what looks to the insurer as sensible budgeting may appear to the patient as unnecessary and unfair rationing.”
If the insurer chooses to refuse coverage, it saves the cost of that service, but it risks losing a whole lot of its good reputation and future enrollees if the woman goes to the media with her story. I’m sure she could find a journalist willing to jump on that story and write it in a way that convincingly makes the insurer seem like the villain.
So, insurers are rationally covering things that could be considered wasteful. This is just one more example of how parties in the healthcare system respond so rationally to incentives. Which means if we can fix the incentives, we can fix the behaviours in the healthcare system.
Ever since the start of residency, the Journal of the American Medical Association (JAMA) has been delivered to my mailbox without me ever subscribing to it. They keep threatening to stop sending them if I don’t pay for a subscription, but I keep finding the journals in my mailbox. Usually I will glance at the titles of the articles and read the ones I find interesting. That is why, this week, I am writing about what I read in the viewpoint article, Reducing Low-Value Care and Improving Health Care Value, by Drs. Allison Oakes and Thomas Radomski.
They start the article by talking about how there’s a lot of low-value care delivered in U.S. healthcare, even in the absence of financial incentives for delivering more care. They cite some studies from places like the VA system and the Alberta, Canada, system (my home province!), showing how they, too, deliver lots of low-value care. This is their great encapsulation of that important insight: “The provision of low-value care when financial incentives are not present suggests that there are other motivating forces that contribute to overuse. . . .”
Next, they talk about regional variation, saying that from one region to another, there are “systemic differences in care delivery.” But how could doctors act so differently from one region to another? Their answer, at least in part, is that “organizational culture influences patterns of low-value service use. Individual organizations have distinct overuse profiles.” I like that phrase: distinct overuse profiles.
And it’s true. Very true. I’ve worked in the midwest, the northwest, and the mountain west, and I see it. For example, almost no one ordered blood ammonia levels at one hospital, and at another it’s an almost expected part of any workup of confusion, even if the patient has no liver history.
Another example: Just today a colleague was telling me about how if she ever ordered a certain kind of fluids (LR), she would get multiple phone calls checking to see if she’d really meant to order that. Evidence is fairly convincing these days that LR is usually better than normal saline, but that hadn’t caught on at her old hospital. At her new hospital, there’s literally a pop-up warning for anyone who tries to order normal saline that says, “LR is better.” And it offers to switch the order to LR for you.
Another example: At my current hospital, I very frequently see a urinalysis ordered on patients who presented to the ED without any complaints that would make me suspect a UTI. And since urinalyses are commonly falsely positive, those questionable urinalysis orders frequently lead to questionable antibiotic administrations. At other hospitals, the ED physicians’ culture is to have a much higher threshold for ordering urinalyses, and even when they are ordered, the likelihood of treating “asymptomatic bacteruria” is much lower.
Another example: The likelihood of the radiologist reading a chest x-ray as having an opacity that could be pneumonia seems to be different from hospital to hospital. And even if the patient hasn’t had any other symptoms of pneumonia, if they have any sort of respiratory complaint and the chest x-ray report says possible opacity “consider pneumonia,” it seems they always end up getting admitted for pneumonia and started on antibiotics.
These are just a few examples of how the practice of clinical medicine is so different from facility to facility in 1,000 tiny ways. And I understand why it happens.
In residency, your practice patterns are being strongly shaped by what your attendings do. But they’re also shaped, to a large degree, by the personal studying you’re doing and by presentations given at noon conferences and morning reports, where the presenter has spent a lot of time reviewing the newest evidence on the topic. There is a ton of active learning, and your connection to the newest evidence is fairly strong. Although, possibly as a side-effect of this, you also seem to add rare diagnoses to your differential more often, and this probably leads to more low-yield testing.
After residency, working as a regular attending not affiliated with a residency program, the focus is very different. The overall goal of practicing medicine is the same–delivering great care for patients–but there isn’t nearly as much active talk about ways your group might be practicing low-value care. (Instead, ensuring adequate coding and documentation dominates the discussion topics.) The connection to the newest evidence is a lot weaker. And there seems to be more of a focus on avoiding malpractice, which leads to having a lower threshold for ordering tests and scans for common diseases, which also counts as low-yield testing when the diagnosis in question is unlikely in that given scenario.
Individual physicians will still learn new things through personal study, but it’s an uphill battle to justify doing something different than your colleagues. So as you take over your colleagues’ lists of patients when you come on service, and as you take over newly admitted patients from the night before, you are frequently seeing and slowly being influenced by how others in your group are practicing medicine. The practice patterns naturally homogenize. I was once asked by a colleague to send an email to my hospitalist group about the evidence backing up something that I was doing because it was different than the other hospitalists.
This is how particular practice patterns spread and homogenize throughout an organization. Combine those effects with the other active pushes for practice pattern changes that come through leadership communications and EMR integrations (like the “LR is better” pop-up warning), and distinct overuse profiles start to make a lot of sense.
All these cultural factors that lead to systemic but regionally different low-value care delivery will need more than simply top-down Medicare reimbursement changes.
I stand by my solution that, if value-sensitive decisions in healthcare became more widespread, the financial incentives for decreasing low-value care would not only change the macro incentives, but they would be strong enough to induce healthcare managers/clinical leaders to go about finding creative and effective ways to make the organizational changes necessary overcome the cultural factors I’ve talked about in this post.