Tag Archives: medical cost management

A Simple Way for Physicians to Take Action Against Overtreatment

“The plural of 'anecdote' is 'policy',” medical historian and health policy expert Dan Fox famously stated. Sometimes a good anecdote can be worth a thousand academic papers in motivating change, and right now healthcare is at a cultural crossroads.

In the current medical world, the default is for more healthcare – more testing, more treatments, more surgery, more stents and more screening. The public understandably, and often correctly, infers that more must be better when it comes to medicine. Physicians have not been able to effectively explain the paradox that in some cases more healthcare does not equal more health, and in fact it sometimes means the opposite.

But we physicians have seen the harms of overtreatment. We have seen patients go on dialysis machines because the contrast from a CT scan destroyed their kidneys. We have seen patients suffer from severe bacterial infections that develop following the inappropriate use of antibiotics (e.g. C. Difficile colitis). We have talked about patients in our “M&M” (mortality and morbidity) conferences that have died on the cardiac cath table undergoing a procedure that they may not have needed.

It is time for us to tell these stories on a broader scale. The innate power of storytelling has been successfully harnessed to improve care and advance medical culture before. More than a decade ago, the infamous analogy likening the number of deaths due to medical errors to a jumbo jet crashing every day gave readers a disturbing visual that drew a visceral response in a way that raw numbers just never will. It helped galvanize the professional and public momentum behind the patient safety movement.

More recently, stories have been paired with data to help drive a new movement that encourages appropriate, rather than just more, care. Atul Gawande’s anecdote about unwarranted Medicare spending in McAllen, Texas, started as a magazine article; it has now become a call-to-arms that was required reading in the Obama White House. The Costs of Care essay contest started as an effort to encourage patients and their caregivers to think about opportunities to improve value; it has now become a robust crowdsourcing mechanism that added necessary clinical detail to the Institute of Medicine’s Best Care at Lower Cost report.

While we modern physicians all (rightfully) worship around the altar of evidence-based medicine and data-driven decision-making, our hearts are still very much shaped by our own stories, experiences and those that we hear from our colleagues. Morning reports, conferences and resident workrooms buzz with the harrowing tales of “I have this patient who…” and “I once saw….” As a result, case reports hold an important place in the history and development of our medical knowledge.

Toward this goal, JAMA Internal Medicine has created “Teachable Moments,” a series for trainees at all levels to tell the stories from the frontlines of healthcare when overuse causes harm.

Together we can change the national narrative and lead to smarter, safer and more thoughtful healthcare that once again is aimed at achieving our shared goal of actually improving people’s health.

Authors

Neel Shah collaborated with Christopher Moriates, MD in writing this article. Dr. Moriates co-chairs the Costs of Care Teaching Value & Choosing Wisely Competition and advises Teaching Value Project development. He speaks locally and nationally about cost-awareness education for physicians and has implemented a cost curriculum for residents at University of California, San Francisco (UCSF) that was highlighted by the New England Journal of Medicine. Dr. Moriates is an assistant professor at UCSF and the co-chair of the UCSF Division of Hospital Medicine High-Value Care Committee.

Data Integrity – Y2K All Over Again?

Remember Y2K?
“January 1, 2000, that is the day that was to change all of our lives. That was the day that the computers on which we all depended would fail us. That was the day that all of our luxuries of daily life would crumble, and we would be once again forced to live without electricity, running water, heat. The great Y2K scare is what it was called. The scare was that all of our computer systems around the world would cease to function on December 31, 1999.”1 They did not.

Drawing A Parallel In Workers’ Compensation
The hype and fear of Y2K were paralyzing for some and organizations spent large sums of money to reprogram computers in preparation. Indeed, there is far less anxiety about the veracity of medical provider data in Workers’ Comp claims and bill review systems. Yet, medical provider records in Workers’ Comp are just as lacking as the year date in systems prior to 2000 and the ramifications could actually be consequential.

Opportunity Cost
The Y2K issue prior to the late 1990’s was caused by limited disk space that was conserved by using only two digits for the year. The number of bytes that would fit on a screen and in the memory of the machine was limited. On the other hand, the cause of limited medical provider data is simply a matter of traditionally paying the bill efficiently. Only name, address, and Tax ID is needed. However, inadequate and inaccurate medical provider data is opportunity cost for the industry.

New Applications
No longer is the industry interested in using medical provider information for bill payment only. Provider records in systems are key to evaluating provider performance beyond direct fees for service. Medical providers impact return to work, indemnity costs, claim duration, and other factors. The indicators can be found in the data.

Who Knew?
Medical provider records have recently risen to the level of essential information for quality and cost control. In order to evaluate individual medical providers, medical groups, and facilities, the data in provider records must be non-duplicative, accurate, and complete. Yet, most databases contain multiple records for the same, and presumably the same provider. Moreover, the records are incomplete, especially regarding unique identifiers such as state license numbers or NPI (National Provider Identifier) numbers that distinguish individuals.

Duplicate Provider Records
One of the major problems found in most Workers’ Comp data is duplicate medical provider records. Duplicates are a problem because the records for an individual are dispersed over multiple records and can only be evaluated separately rather than collectively. The cumulative data for a provider cannot be assessed until duplicate provider records are merged.

Duplicate provider records occur for many reasons. Some organizations simply add a new provider record to their database when a new bill is received, without checking to see if the provider already exists in the data. This is simple to correct administratively, by requiring data entry persons to check the data for the existing provider. A more reliable solution is to create systems with search and select utilities that limit “add” authority. However, duplicate records occur for other reasons as well.

Duplicate medical provider records can also occur when the same provider is added to the database, but the name is spelled differently, a different suffix is used, and when initials or abbreviations are entered differently. Computer systems read these as different and allow adding the new one. Similar address inconsistency has the same result. Using Ste, Ste., and Suite might result in three separate records for the same person or entity. The solution is using basic record search and select from a drop down list. Moreover, correcting the existing data by scrubbing the database is worth the time and cost.

Optimize Medical Provider Records
Tax ID, so important to paying a bill is nearly useless when evaluating medical provider performance because multiple persons often use the same Tax ID. Establishing a critical mass of data associated with one provider is difficult, and duplicate records simply dilute the information further. Certainty about individual identity is critical and the only way to achieve that is with state license numbers.

License Numbers
Unfortunately, NPI numbers, established by the CMS (Centers for Medicare and Medicaid Services) are abused by some. Notorious medical providers apply for and receive multiple NPI numbers. State license numbers are the most reliable and should be added to provider records in databases to differentiate individuals.

Medical Specialty
Including medical specialty in the provider record increases its value exponentially. The most accurate, fair, and illuminating evaluation is comparing peers. Comparing neurosurgeons to dermatologists on some performance indicators makes little sense. Pain specialists, for instance, usually receive complicated cases late in the game and should be compared to other pain specialists, not those who treat acute injuries. Medical specialties are vital to evaluating performance accurately.

What To Do
While it may not be Y2K, the impact of poor data might be greater for Workers’ Comp organizations. Systems should contribute to medical cost management intelligence. However, many cannot because of data quality. Scrub and optimize existing data and establish protocols that prevent continuation of status quo. Outsourcing to a third party specialist is easy and the return on investment certain.

1The Y2K Scare