In developing coverage policies, managed care organizations typically lean on available research for guidance. They comb through technology assessments by state and federal agencies and independent not-for-profit organizations, as well as clinical practice guidelines promulgated by professional societies. Medical minds are put to work interpreting the findings and then ensuring that health care providers in the field practice within that framework in exchange for reimbursement.
Michael Schlosser, MD
Physicians rendering care are usually left out of the loop. They have no real voice in defining what is necessary and appropriate. And aside from current experiments in procedure-specific payment models that shift some risk to providers, they haven’t been held accountable for the financial repercussions of their treatment decisions. They participate in the process only by advocating for procedures and devices they deem medically important, or by appealing a denied claim with corroborating evidence. As a result, the relationship between those delivering health care and those paying for it has been less than collegial, and there’s a persistent belief among physicians that payers hold all the cards.
What if we were to build an infrastructure for value analysis that resides closer to points of care and would open up these types of medical director positions to practicing physicians? Putting more eyes on the evidence would put more focus on how best to take care of patients and drive the utilization patterns toward the highest value options. That is what managed care should be about—not just controlling costs.
Physicians, more than anyone else, can influence peers when it comes to talking about evidence-based care, even when it runs counter to customary, but costly, practice patterns. The timing couldn’t be better to put physicians in this leadership role because of the growing use of value-based payment models.
The simple truth is that physicians in the field are the only ones in a position (often for years) to make a judgement call on treatments not yet appearing in published studies or backed by exhaustive research. With or without the blessing of a payer, physicians at the bedside still often have a medical problem to solve that doesn’t fit neatly into treatment guidelines.
Hospitals have been employing practicing physicians as medical directors in hopes of closing the divide between clinicians and executives and the ongoing disconnect between physicians and supply chain professionals. Recently, HealthTrust, the company I work for, became the first group purchasing organization (GPO) to hire a practicing physician as a medical director for each of three service lines (cardiovascular, orthopedic and spine, and general surgery) to work collaboratively with its clinical boards, contracting teams, and the larger physician community. These new service line medical directors will be working with those groups to vet clinically sensitive products and emerging technologies. They will also work closely with a data scientist and clinical data analytics team to explore how product utilization factors into the cost, quality, and outcomes (CQO) equation. As active leaders of the value analysis process at both the local (health system) and national (GPO) level, practicing physicians will be in a position to argue for coverage using evidence and transparency about how it was evaluated to achieve consensus with their peers about which products and techniques have real value for patients.
We can learn from retired Gen. Stanley McChrystal, the former commander of U.S. and international forces in Afghanistan, who recently spoke at the annual HealthTrust University Conference. McChrystal empowered commanders nearest the action. We should adopt the same approach in health care by empowering practicing physicians to use what they know rather than sticking to the traditional hierarchy where payer-employed medical directors call all the shots.
Not every physician is destined to be this type of leader. But those with the personality and skills needed to address the challenges of true value analysis are the ones that managed care organizations need in their corner. They can help those organizations ensure patients receive the highest quality health care—needed services, delivered at the right time and in the most appropriate manner—which, in the long run, is also the least expensive health care.