2011 Potpourri XXXIV

An editorial in the Journal of the American Medical Association discusses a danger related to evidence-based medicine or more properly the over-reliance on process of care standards as markers of quality.  The author notes that not only is there often weak evidence connecting compliance with process of care standards to ultimate health outcomes, in some cases the standards have led to bad outcomes.  The use of administrative databases or registries to capture compliance with process of care standards does not reflect the clinical judgments or patient preferences that may be involved in individual cases and does not leave enough room for the proper recognition that there can often be good reasons for variation in care processes and that health outcomes don’t necessarily suffer.  This is an extremely valid point, and most of our pay-for-reporting and pay-for-performance programs are very vulnerable to this defect.   (JAMA Editorial)

Victor Fuchs, the noted health economist, writes a New England Journal of Medicine Perspective about the difficulty physicians may have in figuring out what is appropriate care.  A fundamental dilemma facing doctors, he argues, is the conflict between the primacy of patient welfare and the responsibility to be wise managers of expensive and limited clinical resources.  Fuchs blames the rise in spending on third-party insurance, which desensitizes both doctors and patients to costs and on the spread of more expensive medical technology and procedures.  He does not think greater use of patient cost-sharing will help, since so much of total spending is incurred by a few patients who will exceed any reasonable cap.  He thinks that the best solution is to have physicians practicing in groups where there is a budget per patient and the organization has full responsibility for the health of patients.   (NEJM Perspective)

The Workers’ Compensation Research Institute has issued a new version of its medical price index for nonhospital services.  The index tracks prices across almost all states for medical services which are heavily used in workers’ compensation.  The index measures prices actually paid for these services.  It is broken down into major groups of care and allows comparison of trends within a state and for comparisons from state-to-state.  Because there is substantial variation in the regulatory and cost control environment in different states, the index helps analyze the effects of those different regulatory systems or cost control methods.  In general, over the last eight years states with fee schedules have seen lower price increases than those without them.  (WCRI Index)

An article in the Los Angeles Times discusses efforts to reduce hospital-acquired infections in the state.  Medicare and other payers, as well as public health officials, have made preventing these infections a priority.  By some estimates such infections may result in 99,000 deaths and add $33 billion to spending annually.  Among the hospitals participating in the initiative, ventilator-associated pneumonia has dropped 41%, catheter-related urinary tract infections by 24% and blood poisoning by 11%.  Many of the corrective measures are extremely simple:  hand washing, better control of mouth bacteria for ventilator patients, use of checklists and sterilizing equipment.   (LA Times Article)

Research reported in the Journal Circulation finds that hospitals have made tremendous progress in another key quality area–reducing the amount of time between when a patient who has a heart attack is picked up by an ambulance and has a procedure to clear the blocked area. The median time was lowered from 96 minutes in 2005 to 64 minutes in 2010.  Over 91% of patients had times less than 90 minutes and 70% less than 75 minutes.  This reduction in time generally creates an opportunity to avoid less severe lasting damage from the heart attack and gives the patient a better chance of making a full recovery.   (Circulation Article)

A benefits advisory firm released a survey relating to consumer-driven health plans.  The primary findings were that CDHPs grew to 23% of plans offered and cover 17% of employees.  Overall growth in the plans for 2011 is around 14%, which is down from prior years, but still very healthy.  The Northeast has the heaviest penetration of these plans, followed by the Southeast.  CDHP costs rose 8%, which was only slightly less than the overall increase for all plan types.  This suggests that perhaps the cost savings are just due to an initial drop from the increased cost-sharing, but after that the general medical cost trend resumes.  Most employers support an HRA or HSA to help employees with the additional cost-sharing.   (UBA Survey)