Decreasing “unwarranted” variation in clinical care
March 24, 2010
As you read this, we are in the midst of unprecedented reform to our national health care system. The changes are complex and we are actively figuring out what it means for our organization and our patients. While it will lead to many challenges, I also believe it will create more opportunities for delivery systems like ours to focus on better ways to provide care. Our stories today about preference-sensitive care and shared decision making are timely and prime examples of how we are improving care, affordability, and patient satisfaction.
For more than 20 years, scholars at Dartmouth College have analyzed why health care costs vary so much by region. They publish their findings in a respected report known as the Dartmouth Atlas of Health Care. Over the years they’ve determined that more than 25 percent of all health care costs come from variation in the care provided that serves no clinical purpose. (Of course appropriate variation does exist and serves a clinical purpose.) The Dartmouth researchers point out that more intensive care—and more expensive care—isn’t necessarily better care. In fact, in many cases outcomes are worse.
One reason health care varies by region is because of different regional care patterns (ie, medical culture) for certain procedures. The supply of providers and hospitals is also a factor. If a city has a lot of orthopedic surgeons, for example, then you’ll likely see more surgery for joint pain.
Addressing unwarrented variation is further complicated by a category known as preference-sensitive care. For many conditions, there isn’t a single best treatment. Patients can choose between several viable options such as having an invasive procedure or taking a “wait and see” approach.
A classic example of a preference-sensitive condition is a retiree deciding whether to have knee replacement surgery or to go with medications and physical therapy. Caregivers must factor in the patient’s values and lifestyle preferences with the medical evidence and help the patient make the best decision for their needs and values.
Research shows that good communication from clinicians about options and consequences for preference-sensitive conditions makes patients happier with their treatment decisions and can decrease health care costs.
Under health reform, the federal government is exploring changing reimbursement to motivate health care providers to use proven, evidence-based practices. This shakes up the status quo. Recently articles in the New England Journal of Medicine and New York Times have challenged the Dartmouth Atlas’s research methods. At Group Health we’ve watched the debate with interest, but are convinced that the Dartmouth group is accurate in its key finding of no consistent link between costs of care provided and the quality outcomes of that care.
At Group Health we strive to practice medicine that’s based on evidence whenever possible. We are working hard to examine our own practice patterns, establish “best practices”, and partner with patients around their care decisions.
Increasingly, we encourage patients to consider all the options and make an informed choice based on what we do know and the patient’s values and preferences. This is called shared decision making, and it’s a cornerstone of where we are going at Group Health.
During the past 18 months, Group Health has built new processes to promote shared decision making for preference-sensitive care. I’m proud that Group Health is finding ways to be part of the solution.
- | 2011
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