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P E R S P E C T I V E S
V A R I A T I O N S
W E B  E X C L U S I V E   

7 October 2004  
  

Perspective: 
When Excuses Run Dry: 
Transforming The U.S. 
Health Care System

Media attention alone is not sufficient to spark a transformation;
real commitment and cultural change are necessary.

By Leonard D. Schaeffer and Dana E. McMurtry

ABSTRACT:

Mainstream media have reported on the wide variation in clinical practice documented for years by health service researchers. Raising awareness of the quality and cost implications of clinical variation, however, is not enough to adopt clinical behavior based on the principles of evidence-based medicine (EBM). Preoccupation with EBM’s limitations—which can be overcome—and failure to address its misperceptions inhibit transformation to an evidence-based system of care and payment. Three reinforcing efforts are needed: aligning payment with quality; increasing the engagement of consumers; and accelerating investment in and adoption of information technology. Real transformation in health care requires changes in both culture and attitudes.

The papers in this collection add to the literature linking variations in clinical practice to wide differences in quality of care and health outcomes.¹ The message is that aggressive short-term action is needed to implement a long-term vision to accelerate translation of research into clinical practice. This long-term vision aims to make evidence-based medicine (EBM) the “gold standard” for care.² Research stretches back four decades showing gaps between what is known to work and the care patients get.³ Excuses are running out for maintaining a health system that fails to optimize quality of care.

Reports by the Institute of Medicine (IOM) and RAND have struck a chord with the public.⁴ The media have begun to focus attention on these issues, but this alone is not sufficient to change behavior and generate a shift to EBM.

Barriers to adoption of EBM. A review of the literature reveals that barriers to adoption of EBM can be classified into two distinct categories: limitations and misperceptions.⁵ Limitations include difficulties in applying evidence in the care of patients, the need to develop new skills, limited time and resources, and lack of evidence that EBM “works.” Most of the limitations cited can be addressed through training, new skill development, and acquisition of tools that provide decision support at the point of care. The notion that EBM lacks evidence is refuted by consistent findings that patients receiving proven therapies have better outcomes.⁶

Many of the limitations to practical application of EBM are no different than the everyday challenge physicians face as scientists whose work has an experimental and changing basis.⁷ Most physicians recognize that the potential to provide their patients better care resides in the ever-growing body of clinical research. The challenge for the system is to translate research into common protocols for specific diagnoses, disseminate the information widely to help physicians stay current, and create incentives to promote application.

Misperceptions of EBM as a “cost-cutting” tool benefiting payers or a “cookbook” approach that treats every patient exactly alike inhibit efforts to put research into practice.⁸ These misperceptions foster provider distrust, provoke unnecessary defenses of unfettered professional discretion, and create barriers to institutionalizing evidenced-based interventions that would improve outcomes and lower the avoidable costs of poor quality.

Misperceptions of EBM may stem from lack of a common definition. EBM is not a new concept, but older definitions overemphasize the requirement to use statistical evidence in making clinical decisions about the care of individual patients. EBM today acknowledges that a physician’s best care combines guidelines based on scientific data, the physician’s own experience and knowledge, and an understanding of patients’ values and preferences.

Patients’ needs and responses differ, and physicians’ experience is critical to discerning what works best, has the best compliance, and is the most cost-effective.⁹ Greater reliance on EBM would actually increase use of proven technologies and therapies and reduce the overuse of treatments with insufficient evidence and marginal clinical usefulness. Also, the research community should heed Helen Darling’s call for comparative clinical effectiveness studies to help physicians combine knowledge with their professional intuition.¹⁰

Transformation to an evidence-based system. Growing national attention to the importance of clinical quality emboldens those interested in EBM. WellPoint and other leading health plans are already employing multiple strategies that incorporate the principles of EBM. These include disease management/ health improvement programs, physician profiling, improved pharmaceutical and therapeutic review processes, dissemination of quality information to network providers, and collaboration with business and trade groups on quality initiatives.¹¹

At issue, however, is that neither the media nor these programs will be the change agent that establishes EBM as the foundation of U.S. health care. Changing the economics of health care is what’s needed to transform the system. For this reason, health plans’ responsibility for financing health services naturally consigns plans to a change-agent role. Plans can most effectively catalyze change in practices and behavior using their unique position in the health care system as payers and intermediaries of information.

In the current system, poor quality pays: Physicians are reimbursed for both incorrect treatment and effective therapy.¹² They are also reimbursed for care that may not inflict actual harm but may be duplicative and of marginal clinical value or may put the patient at risk. Patients, too, contribute financially to questionable care. A potent way of reducing tolerance for low quality throughout the health care system is to migrate toward a quality-based system of payment.

Transformation to an evidenced-based system of care and payment requires three changes to the status quo: (1) aligning payment with the provision of high-quality care; (2) motivating patients to become better health care consumers; and (3) accelerating the investment in and adoption of information technology (IT) that supports compliance with and further development of EBM. Ideally, all three changes should occur in rapid unison. Health plans recognize, however, that consumers and providers prefer to act voluntarily, usually in reaction to subtle incentives—a social value resulting in incremental change to U.S. health care.

Mindful of this social value, health plans are targeting financial incentives at physicians and patients—the two parties who share (or should share) clinical decision making—as a first step toward new quality-based payment models. At the same time, there is a need for health IT that supports exchange of clinical and administrative data among providers, patients, and plans. More sophisticated IT and more standardized data definitions are a prerequisite to sustaining changes in clinical practice and office workflows that make better care possible.

Aligning payment with quality. WellPoint and other leading health plans have implemented voluntary physician incentive programs to pay for quality because physicians accept this approach. Our experience demonstrates that incentives can prompt physicians to change their clinical behavior. Bonus payments can also influence physician groups to install IT to measure quality, improve care, and reduce errors.

The reality of pay-for-performance, however, is that the size of the incentive matters. The extra revenue is a function of how many members a physician sees from a particular plan. The incentive and enrollment must be sufficient to alter behavior and spur quality investments in the office. For this reason, Bradley Strunk and Robert Hurley observe that raising the bar on quality throughout health care will depend on “plans with larger market share who are more likely to succeed than efforts by smaller plans.”¹³

Rewarding providers who demonstrate quality is important; rewarding providers who demonstrate quality improvement will become even more critical to moving the dial on quality. The biggest challenge for maturing pay-for-performance programs will be finding acceptable ways to provide incentives for physicians who are reluctant to change clinical behavior or use IT associated with higher quality.

Creating better consumers. Consumers are as disconnected from decision quality as they are from the true costs of care. Annette O’Connor and colleagues define “decision quality” as patient participation in clinical decision making. The lack of such participation results in the overuse of options that patients do not value and higher health care costs.¹⁴ Helping patients make value-based choices is emerging as a key strategy for both quality improvement and cost containment.

The current system cocoons patients instead of encouraging them to actively participate in decisions about their own care. Lack of consumer engagement in cost-effective care perpetuates a supply-driven model of insatiable and unaffordable demand. Consumer engagement isn’t code for “increasing cost sharing.” It means helping consumers become informed so they can factor in their values when evaluating the benefits versus the harms of different treatment options.¹⁵

The onus is on health plans to develop benefit designs that encourage consumers to value clinical quality, insist on shared decision making, and accept the responsibility to bear the results of choosing lower-quality treatment options. This should not, however, deter patients from seeking needed care.

Accelerating IT adoption. Long-term quality improvement requires accelerating the adoption of health IT systems throughout the health care system. Health IT is needed to facilitate the flow of clinical information, integrate and analyze data to generate performance metrics and new information, and transfer that knowledge back to empower patients and change clinical behavior.

Momentum is clearly building to implement interoperable IT systems that can make health care safer. Credible studies show that an unacceptable number of patients die from medical and hospital errors each year.¹⁶ The good news is that electronic prescribing demonstrations are showing dramatic reductions in the errors responsible for many deaths.¹⁷ Unfortunately, some stakeholders focus only on the methodological limitations of this research. This dilutes calls to action and fosters a “culture of denial and complacency.”¹⁸ It is clear that only combined and sustained public- and private-sector efforts will eliminate resistance to wider adoption of health IT.

Government can wield its purchasing power to this end. The electronic prescribing requirements to support Medicare Part D, for example, will help quicken the pace. WellPoint’s experience with its $42 million Physician Technology and Quality program shows that health plans capable of large-scale initiatives can also “seed” the physician market with health IT. This program gives physicians a free gift of either a handheld electronic prescribing device or a computer system designed to help them participate more fully in the electronic medical community.

Multiplying similar private-sector efforts to improve clinical decisions would reduce variation, create a spillover of high-quality care to more patients regardless of their carrier, and tip the system toward evidence-based care. The WellPoint Foundation recently established the Center for Health Care Economics and Technology to encourage such private-sector efforts.

Changing values and attitudes. Large-scale change within systems is not easy. Yet it is sobering to read Fitz Mullan’s interview of Jack Wennberg, which reminds us that he and his colleagues have documented treatment variation since 1973.¹⁹ Their key insight back then was that the paradigm of ongoing translation of science into effective care was a myth. There are now many more treatment options with important trade-offs for patients to understand if they are to share in making clinical choices.

The real transformation in health care will be changing values and attitudes. A culture is needed that demands to know how we can reduce variation through EBM, not why we can’t. We have the tools, incentive strategies, and attention of stakeholders that can be leveraged to break down the barriers that paralyze progress. Above all, we have the obligation to assure broader access to affordable coverage.

The authors thank Health Affairs for continuing the dialogue on clinical variations and quality. They also thank the excellent Health Affairs staff for their assistance.

NOTES

1. A special collection of papers and commentaries is available at content.healthaffairs.org/cgi/content/full/hlthaff.var.117/DC1.
2. America’s Health Insurance Plans, “A Commitment to Improve Health Care Quality, Access, and Affordability,” Board of Directors Statement (Washington: AHIP, March 2004).
3. RAND, “The First National Report Card on Quality of Health Care in America,” RAND Research Highlights RB-9053-1 (2004): 4.
4. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academies Press, 1999); Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001); and E.A. McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine 348, no. 26 (2003): 2635–2645.
5. S.E. Strauss and F.A. McAlister, “Evidence-Based Medicine: A Commentary on Common Criticisms,” Canadian Medical Association Journal 163, no. 7 (2000): 837–841.
6. Ibid.
7. J. Jaffe, “Evidence Based Medicine: Putting Research into Practice,” EBRI Notes 25, no. 2 (2004).
8. L. Landro, “A Carrot for the Right Prescription,” Wall Street Journal, 6 May 2004.
9. Helen Darling, president, National Business Group on Health, Statement to DHHS Listening Session on Research Priorities under MMA 2003, 21 May 2004.
10. Ibid.
11. P.H. Keckley, “Evidence-Based Medicine in Managed Care: A Survey of Current and Emerging Strategies,” Medscape General Medicine 6, no. 2 (2004).
12. Remarks of Gail R. Wilensky, senior fellow, Project HOPE, in “The Future of Medicare: A Discussion Forum about Medicare Reform and Growth,” Supplement to Managed Care (September 2003): 17.
13. B. Strunk and R. Hurley, “Paying for Quality: Health Plans Try Carrots Instead of Sticks,” Issue Brief no. 82 (Washington: Center for Studying Health System Change, May 2004).
14. A.M. O’Connor, H.A. Llewellyn-Thomas, and A.B. Flood, “Modifying Unwarranted Variations in Health Care: Shared Decision Making using Patient Decision Aids,” Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.var.63.
15. Ibid.
16. HealthGrades, “Patient Safety in American Hospitals” (2004).
17. D.W. Bates et al., “Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors,” Journal of the American Medical Association 280, no. 15 (1998): 1311–1316.
18. S. Collier, author of the HealthGrades study, as quoted in Wall Street Journal, 27 July 2004, and reproduced by the National Journal Group Ltd.
19. F. Mullan, “Wrestling with Variation: An Interview with Jack Wennberg,” Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.var.73.


Leonard Schaeffer is chairman and chief executive officer of WellPoint Health Networks in Thousand Oaks, California. Dana McMurtry (Dana McMurtry{at}wellpoint.com) is WellPoint's vice president for health policy and analysis.

DOI: 10.1377/hlthaff.var.117
©2004 Project HOPE–The People-to-People Health Foundation, Inc.