Applying EBM
Provider Payment Systems
In contrast to an earlier time, when health maintenance organizations represented a popular form of managed care, most provider payment systems today are fee-for-service. This has created financial incentives for doctors and hospitals to focus on volume of services delivered rather than the quality, cost, or efficiency of care. The proposed healthcare reform plan requires that significant investments be made to develop and report quality of care measures across the health care delivery system. It is believed that, ultimately, this should lead to higher quality of care for all patients. It bears mentioning that the objective of moving away from a fee-for-service model can be supported by evidence from the 1990s, during which greater reliance on managed care led to a considerably slower growth of healthcare costs.
Pay For Performance
On the forefront of proposed reform legislation, collecting and reporting of quality data has currently taken the form of the Physicians Quality Reporting Initiative (PQRI) with many payors instituting their own versions of pay-for-performance (p4p) programs. Through such initiatives, quality data is reported via performance measures. These measures, based on credible evidence, are developed through a sophisticated process by work groups and, often, evidence-based treatment guidelines. Essentially, the rationale for the performance measures must first be explained. Following this, the measures are then clarified, scrutinized, and ultimately approved. The final version of each approved measure is then voted upon.
Health Information Technology
Still relatively young – just over a decade since its foundations were first established – EBM faces challenges in integration into clinical practice. Due to the sheer volume of published material, it remains quite a challenge for physicians to sift through all relevant findings and data in order to stay informed and up to date. Evidence-based abstraction journals can make the process more manageable. Other approaches include attending lectures and conferences, participating in study groups, and speaking with colleagues and specialists. While the production and summarizing of relevant evidence is ongoing, vital to the process is dissemination of information. HIT can aid these efforts by enabling more comprehensive documentation, elevating control of patient compliance, and providing an efficient way to manage database files by enhancing decision support with reminders, directives, feedback, audit, and reporting capabilities. The use of health information technology (HIT) can increase the rate at which performance data can be exchanged. Once the data has been accumulated, risk-adjusted provider performance profiles could then be made available to encourage quality improvement and keep consumers better informed.
Studies reflect that when clinicians have access to information, it changes their patient care management decisions. For this reason, it is crucial that resources be current, and easily accessible. While clinicians have historically referenced literature to guide decision-making, EBM formalizes the process and filters available resources. There are challenges associated with conducting effective searches to identify best evidence. However, health information technology (HIT) can assist in clinical decision making and the use of evidence-based guidelines by providing a conduit to collect and analyze data to ensure quality standards are met. HIT compliments the pursuit of conducting best practices in healthcare and can greatly expedite this task. The federal stimulus funding made available under the American Recovery and Reinvestment Act 2009 to encourage the adoption of such technology reveals an inherent logic. The ultimate vision behind implementation of HIT is to enable significant and measurable improvements to the health of the population by – among other things – improving quality, efficiency, and coordination of care. And these goals can only be achieved through the effective use of information to support better decision-making that ultimately serves to improve outcomes.
Improving Outcomes
US healthcare spending has risen dramatically in recent decades relative to spending in other countries, with no evident gains in outcome. Perhaps even more compelling evidence of inefficiency comes from within the United States. Utilization and per capita healthcare spending vary substantially by geographic region. Yet, in many cases, these variations are not associated with substantial differences in health outcomes. In light of these factors, our administration believes that total healthcare expenditures could be cut without adverse health consequences. Put another way, efficiency improvements in the US healthcare system could free-up resources equal to a meaningful percentage of US GDP.
Under healthcare reform, physicians will bear greater responsibility for meeting guidelines and directives. It is hoped that this new set of objective measures will provide structure and direction and that empirical data will serve as the new model by which we measure performance and calculate incentives. As these changes materialize, it is important that we in the healthcare community ensure that the values and preferences of the medical practitioner continue to carry weight in clinical management decisions, and that these are always consistent with patients values.
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