Try this experiment: When a friend (who doesn’t work in benefits) says that she is trying to find the best doctor, ask her what she means by that. While she might value a good recommendation or focus on how much time the doctor spends with her, many of us in the benefits profession have learned to define a quality provider as one who offers the right care, at the right place, at the right time. This is a doctor who will discourage underuse – perhaps by alerting you to a preventive screening you need – and will protect you from misuse and overuse – for example, by recommending physical therapy rather than a back surgery when you present with back pain.
Misuse and overuse of medical services harms patients and wastes money. An Institute of Medicine Study found that about one-third of healthcare expenditures within our system can be classified as waste. Improving quality to reduce waste could be employers’ single biggest opportunity to manage cost. But if waste is an inherent problem in our healthcare system, what can employers do to bring about positive change?
Awareness is key – and so is breaking down the problem into smaller pieces. I want to share with you the approach that Mercer’s Quality Improvement Collaborative has taken to prioritize quality issues for employers to be aware of and take steps to address. (QIC brings employers and healthcare systems together to discuss quality issues.) Because services delivered in the hospital setting – including surgeries and procedures – account for 32% of healthcare costs , we’ve focused on a subset that are often unnecessary, and how we might prevent these. Rather than tackle every single instance of overuse, we’ve zeroed in on 7 areas which are widely acknowledged as presenting an opportunity for improvement:
- C sections The C section rate in the US has showed a remarkable rise between the early 90s and late aughts, climbing from below 25% to almost 33% in 2009, and has stayed at about that level ever since. Unnecessary C sections on first-time moms tend to have a domino effect, as future deliveries are then often C sections as well. Thus a good target is unnecessary C sections performed on low-risk women (full-term, singleton, vertex presentation) and getting this rate down to the Healthy People 2020 goal of 23.9%.
- Unnecessary back surgeries The literature indicates that two-thirds to three-fourths of back surgeries performed in the US are unnecessary. Employers have long tried to tackle this through offering second opinion services to their members, but new avenues for change are needed, with the health system playing a more active role in reducing inappropriate surgeries.
- ER overuse Inappropriate use of ER services are a continuing source of concern to employers. Employers need to engage health systems in a discussion around what steps are being taken within the ER to discourage unnecessary visits, and making connections back to the member’s primary care provider.
- Readmissions A good goal is to reduce 30-day readmission rates, with a focus on avoiding preventable stays.
- Radiology There is significant overuse of medical imaging, which causes harm in multiple ways: physical harm to the member through exposure to greater amounts of radiation, psychological harm from false positives and incidental findings and financial harm through the use of unnecessary resources. Employers and health systems need to discuss strategies they might employ to reduce overuse of imaging.
- Cardiac care Catheterization procedures (diagnostic angiograms and angioplasties) is a particularly common area of overuse within cardiac care.
- Never events These are serious medical errors that should never happen - for example, the sponge left inside a patient by mistake during surgery. Hospitals need to track and report on these transparently, so we can acknowledge the problem, understand its magnitude and act to address it.
Before we can improve quality, we have to define it – and then engage in a productive dialogue with healthcare providers about how to move the needle in the right direction.
You can join a QIC chapter to engage directly in conversations with health systems. Contact Sharmila Shankarkumar at 212 345 2746