There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system—but it’s often not as simple as it seems, according to an article posted on the California Healthline website. Some experts estimate that at least $200 billion is wasted annually on excessive testing and treatment. This overly aggressive care can also harm patients, generating mistakes and injuries believed to cause 30,000 deaths each year.
In California, three of the state’s largest health care purchasers have banded together to promote care that’s safer and more cost-effective. The California Public Employees’ Retirement System (CalPERS), the Covered California insurance exchange, and the state’s Medicaid program, known as Medi-Cal—which collectively serve more than 15 million patients—are leading the initiative.
Progress has been slow, the article says, but there have been some encouraging signs. In San Diego, for example, the Sharp Rees–Stealy Medical Group said it cut unnecessary laboratory tests by more than 10% by educating both doctors and patients about overuse.
A large public hospital, the Los Angeles County–University of Southern California Medical Center, eliminated preoperative testing deemed superfluous before routine cataract surgery. As a result, patients underwent the surgery an average of six months sooner.
These efforts were sparked by the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation, according to the article. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit. The campaign encourages medical providers to hand out wallet-sized cards to patients with questions they should ask to determine whether they truly need a procedure.
The state effort, called Smart Care California, is in the early stages. Initially, the group has focused on cutting the number of elective cesarean sections, reducing opioid use, and avoiding overtreatment in patients with low back pain. In its contract with health insurers, the Covered California exchange requires that its in-network providers meet a range of quality standards, including low C-section rates.
At Cedars–Sinai Medical Center in Los Angeles, however, officials said that economic incentives still drive hospitals to think that more is better.
“We have excellent patient outcomes, but it’s at a very high cost,” said Dr. Harry Sax, executive vice chairman for surgery. “There is still a continued financial incentive to do that test, do that procedure, and do something more.”
In addition to financial motives, Sax said, many physicians still practice defensive medicine out of fear of malpractice litigation. Also, some patients and their families expect antibiotics to be prescribed for a sore throat or a computed tomography scan to be performed for a bump on the head.
To cut down on needless care, Cedars–Sinai arranged for doctors to be alerted electronically when they ordered tests or drugs that ran contrary to 18 Choosing Wisely recommendations. The hospital analyzed alerts from 26,424 patient encounters from 2013 to 2016. All of the guidelines were followed in only 6% of those cases, or 1,591 encounters.
Sax said Cedars–Sinai studied the rates of complications and readmissions, the length of stay, and the direct cost of care among the patients in whose cases the guidelines were followed and compared those outcomes with cases where adherence was less than 50%.
In the group that didn’t follow the guidelines, patients had a 14% higher incidence of readmission and a 29% higher risk of complications. Those complications and longer stays increased the cost of care by 7%, according to the hospital.
In 2013, the first year of implementation of the Choosing Wisely guidelines, Cedars–Sinai said it avoided $6 million in medical spending.
In Northern California, Ann Marie Giusto, an executive at a large hospital chain, meets with doctors to present data on how many tests or prescriptions they order and how that compares with others. At one clinic, she shared slides showing that some doctors were ordering more than 70 opioid pills at a time while others prescribed fewer than 20. In response, Sutter set a goal of 28 tablets in hopes of reducing opioid abuse.
“Most of the physicians changed,” Giusto said. “But there were still two who said, ‘Screw it. I’m going to keep doing it.’”
Source: California Healthline; May 19, 2017.