Weekend Potpourri III

By November 7, 2009Commentary

Washington State has a technology assessment group whose work is binding on all public payers in the state.  A New England Journal of Medicine perspective describes the program.  (NEJM Perspective) At a modest cost, it appears to provide useful guidance on products and procedures which have untested benefits and costs.  The effort may create net cost savings.  As with many state programs, lessons can be learned for the entire country.

The current issue of JAMA has a commentary  regarding the potential conflicts between guideline driven care, particularly when coupled with pay for performance, and patient centered care.   (JAMA Commentary) (registration may be required)  The commentary is yet another example of how complex it is to effectively improve quality.  The increasing prevalence of guidelines for care and pay for performance programs that use adherence to those guidelines risks ignoring patient preferences.  Guidelines are often based on research that averages effects across an entire population–subpopulations or individuals may be affected differently.  Some guidelines are based on research that is subsequently shown to be erroneous or misleading.  Another recent commentary on this site described the rethinking of routine screening for breast and prostate cancer.  While well-intentioned, pay for performance programs that don’t allow for patient choice or for patient-individualized treatment are probably not going to contribute to real quality improvement.

The National Committee for Quality Assurance released its 2009 State of Health Care Report.  (NCQA Report) In somewhat alarmist tones, the NCQA describes a flattening of quality improvement, based on HEDIS measure results from almost a thousand health plans covering 116 million Americans.  It should be noted, consistent with the first item above, that this is a population based quality system that does not look at individual patient needs or outcomes.  HEDIS has utility as an overall barometer, but there are many questions about measurement and reporting, as well as interpretation of results.  The report provides, however, a very useful background on quality measurement.

Pharmacy benefit manager Medco, in conjunction with the AMA, conducted a survey of 10,000 physicians in regard to pharmacogenetic testing.  (Medco/AMA Survey) Pharmacogenomics uses individual variation in gene expression patterns, particularly drug-metabolizing genes, to understand variation in response to medications.  The survey found that most physicians recognize the value of this testing, but few feel knowledgeable enough to use test results effectively.

Uwe Reinhardt is a well-regarded health economist.  In a New York Times blog post, he gives a somewhat amusing explanation of how the CBO scores health reform, or any other, legislation.  (Reinhardt NY Times Blog)

A group called the Committee for a Responsible Federal Budget released a paper looking at the effect of health reform bills on the federal deficit.   (Budget Watch Paper) The group basically finds that none of the current proposals will actually do much to reduce cost trends or the deficit.

The Boston Globe reports on an effort by payers to help Children’s Hospital Boston control its costs in return for the hospital limiting price increases to the payers.  (Globe Story) This is an underused and potentially excellent avenue to cost control.  Helping providers reduce their input costs allows them to lower prices without giving up margin.

Finally, if you have a chronic disease you will be happier if you give up hope that things will get better, according to a study on colostomy patients by the Center for Behavioral and Decision Sciences in Medicine at the University of Michigan.  (UMich. Press Release) Accept your fate, move on and you will feel better.  None of that rage, rage against the dying of the light either.

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