In addition to the study on waste that Charlie cites, NEHI recently published a policy paper with answers to the question: “When data exist, why do physicians NOT adhere to evidence-based practice guidelines?” This research included a Harris Interactive nationwide physician survey and found four interesting barriers to guideline adoption (full report at http://www.nehi.net):

1. Guideline Development – Guidelines are not readily accessible at the point of care, their development is not well understood, and they are not matched to the complexity and context of real clinical decisions;

2. IT Systems – Information technology is not yet available to make guidelines more broadly available;

3. Payment – Payments correlate with volume of procedures versus quality of outcomes; and

4. Physician Culture – Judgment and personal experience, not comparative feedback, govern and motivate physicians.

While it is discouraging to know that we don’t do the right thing for patients, even when clear evidence demonstrates what the “right thing” to do is, there is reason for optimism: Physicians believe that guidelines will have a major influence on clinical decision-making over the next five years. First, we must overcome these barriers. In addition to encouraging the application of innovation to guideline use, we must create a culture that steers physicians toward adopting clinical guidelines. Charlie and the previous commenters are exactly right: reducing waste created by clinical practice variation is critical to true reform in our health care system. We can’t wait any longer to begin.

Please note, on page 24 of the NEHI report, in the conclusions section, two interesting points:

4. Failure of the Primary Care System to Provide Timely Access

5. Underuse of Cost Effective Diagnostic Tools.

(They conclude the latter point by wondering “whether the testing needs to be physically available in physician offices or is better placed in more accessible locations such as pharmacies.”)

I have written before that, so far, there are no adverse financial consequences for either doctors or hospitals that provide more care than is necessary or appropriate. Indeed, they are financially rewarded for doing so under our fee for service system. We need to develop new payment approaches like bundled pricing for expensive surgical procedures that reward value instead of just volume. I also think grouping doctors and hospitals into tiers like drugs are now, combined with lower patient co-pays for providers in the preferred tier, could help to steer patients toward the most cost-effective providers. Referring doctors would need a user friendly system to enable them to easily identify the most cost-effective doctors, hospitals, imaging centers and labs.

At the same time, the ranking system used to develop such tiers needs to be transparent with plenty of input from doctors and hospitals. There also needs to be an effective appeals mechanism to enable providers to challenge their ranking if they think the information used to develop it is incorrect or unfair. Insurers must process these appeals on a timely basis and reimburse both providers and patients that were underpaid or overcharged due to an incorrect (too low) ranking.

The bottom line is that incentives matter. That includes financial penalties for those who provide unnecessary or inappropriate care as well as tangible rewards in the form of either higher payments, gain sharing and/or more patients for the most cost-effective providers.

Why do you suppose that the country’s most visible politicians - those who could actually push change and really help to reduce health care costs - ignore statistics like these? It seems to me that they are more interested in offering up a “quick fix” solution, ie, single payor like Canada. Speak with a Canadian, and it becomes obvious that the Utpoian image of single payor health care is more myth than reality. But ask one of our country’s leaders to take steps to truly tackle the issue(s) facing our industry, and all we get is the same-old same-old. It is really disheartening to know that solutions do exist, but our elected officials do not possess the backbone to do anything concrete about it.