Fwd: qotd: Do we want to avoid low-value care?

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-------- Original Message --------
Subject: qotd: Do we want to avoid low-value care?
Date: Fri, 4 Apr 2014 13:54:54 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The New England Journal of Medicine
April 3, 2014
Avoiding Low-Value Care
Panel: Atul A. Gawande, M.D., M.P.H., Carrie H. Colla, Ph.D., Scott D.
Halpern, M.D., Ph.D., M.Bioethics, and Bruce E. Landon, M.D., M.B.A., M.Sc.

(Excerpts here are not in continuity.)

Atul Gawande: When a service is widely recognized as providing little
or no benefit, or maybe even harm, what should be done to reduce its use?

I want to start with a seemingly simple question. How do you define
low-value care?

Bruce Landon: It turns out that there are very, very few services that
are low-value in all clinical situations. So I actually think it's
really important to use a clinical lens, and particularly for, as I'm
taking care of patients, it's a lens that really focuses on that patient
in front of me.

Scott Halpern: Well, I think it's incredibly difficult to draw lines,
particularly because all our definitions are predicated at the
population level. And population-level estimates don't apply very
naturally to individual patients.

So when we describe something as low-value, I think what we're typically
trying to do is to distinguish it from something that is no-value. But
it turns out that no-value interventions, first of all, are probably
very few and far between. There are very few things we do in medicine
that truly could not help any patient to which we might consider
applying it.

Landon: I think it's going to be hard to address the problem of
low-value care by having payers and policymakers make rules, because
there's this clinical heterogeneity story.

Halpern: The right rates at which we utilize these quote-unquote
low-value services is not zero. We don't want to practice so frugally
that we're missing opportunities to provide benefits to patients by not
intervening. So I think at some level, physicians should be comfortable
that they can make clearly well-thought-out choices that, although there
are recommendations not to do things for the overwhelming majority of
patients who fit a particular description, that there may be exceptions
where the service is in fact a reasonable choice.

Carrie Colla: I think that there's a danger that blunt payment
instruments will reduce the high-value care as well, and so I think to
some extent that's why thinking about it at a broader level while also
monitoring outcomes, but thinking about it at a broader level in terms
of payments makes more sense.

Gawande: What would you say that the policies of the government ought
to be, or of insurers ought to be, in order to make sure decision making
more effective for both patients and physicians under these circumstances?

Halpern: If we had one health insurance coverage system, all the prices
would be a lot easier to keep track of, for physicians and patients
alike. And it would be much easier to have a set menu at the bedside as
these conversations are unfolding, of all the types of information that
we would want. I recognize that may be a long way away. But it is one of
the sort of unintended consequences of our variegated reimbursement
system as it exists today.

Video (30 minute) and link to transcript:
http://www.nejm.org/doi/full/10.1056/NEJMp1401245?query=TOC

****

Comment by Don McCanne

Diagnostic and therapeutic interventions that are of low value remain a
dilemma. In this age with an emphasis on containing costs, should
interventions that have a high cost in relation to an anticipated
minimal or negligible benefit be avoided simply to help "bend the cost
curve"? Or should such interventions be offered since even the smallest
potential benefit should not be withheld from the patient if the patient
desires such?

The easiest decision to be made would be about interventions that
clearly provide no benefit under any circumstances, and may even
potentially inflict harm. This is not low-value care, but rather it is
no-value care. Obviously such interventions should be abandoned. For the
few health care professionals using them who fail to respond to
educational processes, discipline should be considered.

What about interventions that have a significant risk of major harm but
could provide a small benefit that is not commensurate with the
potential harm? Clinical judgement begins to enter here, but it would be
a rare circumstance where other factors may warrant proceeding with the
intervention.

What about the intervention that is very expensive but potentially
provides only minimal benefit? Although some might use measures such as
anticipated increase in quality-adjusted life years (QALY), there are
levels of spending that common sense tells you are far beyond the value
of the potential benefit. Rejecting such interventions risks being
labeled as rationing, but such a charge does not mean that common sense
should be abandoned.

A variation of this category would be lucrative procedures in widespread
use for which only a paucity of conflicting data provides a rationale
for these practices - high cost but low benefit. Sometimes these
correlate with excess capacity in the system, a problem that separate
budgeting of capital improvements could improve. Also, administered
pricing could lower payments to more closely match the extent of the
benefit.

What about the expensive diagnostic intervention that has a very low
probability of of turning up a disorder for which therapeutic
interventions could be of great benefit, perhaps even life saving? This
is where clinical judgement and being sure that the patient is well
informed play a crucial role. This is also where those citing the
Dartmouth studies hope to reduce health care spending. But if a
low-yield test has a real chance of leading to an intervention of
potentially great benefit, then the payer should not intervene.

A frequent criticism is that such low-yield tests are done too often to
reduce the risk of a malpractice lawsuit, and that we could reduce the
costs of malpractice if we did away with these "unnecessary" tests.
Since such tests are low yield, frequently nothing significant is found
and therefore no lawsuit was prevented. But the judgement should not be
based on the cost per lawsuit prevented, but rather on the clinical
benefit to the patient. This is why attacking low-yield tests is not a
productive way of reducing malpractice costs.

What about the patient who demands an intervention when it is clear that
there is no value in what the patient wants? It is the health care
professional's responsibility to inform the patient why such an
intervention should not be entertained. Most patients will appreciate
informed advice. For the rare ones that do not, physicians should never
conspire with a patient to do wrong, even if it results in the patient
seeking care elsewhere.

In all of these situations, the interests of the patient must come
first. Clinical judgement is required for most of them.

So how do we address the costs? The current leading approaches are to
erect financial barriers to care and to impair access by using narrow
provider networks. These interventions are inappropriate because they
save costs by preventing the patients from receiving appropriate care
that they should have.

There is a far better method of reducing inappropriate spending, and
that would be to enact a single payer system - an improved Medicare for
all. Such a model dramatically reduces administrative waste and improves
pricing of health care services. Under a single payer system it is much
easier to match payment with value.