Wednesday, December 8, 2010

Evidence Based Medicine, Medical Malpractice and Incentives

A recent Dustin Comic like all good comics hit the proverbial nail on the head



Unfortunately the healthcare reform fails to address key aspects to the incentive problem in healthcare. The system remains centered on measuring what we do for patients rather than the end result.

There are moves by employers and the insurance industry to incentives patients towards healthier behavior. This approach is not without problems as highlighted in this piece in the New England Journal of Medicine "Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives" where the authors highlight the challenges for employers, employees and insurance in creating incentive and how this can introduce inequities that do more harm than good. As they point out
If people could lose weight, stop smoking, or reduce cholesterol simply by deciding to do so, the analogy might be appropriate. But in that case, few would have had weight, smoking, or cholesterol problems in the first place
There is no doubt that patient incentives must be part of the solution but require thoughtful design and implementation to avoid the pitfalls
Incentives for healthy behavior may be part of an effective national response to risk factors for chronic disease. Wrongly implemented, however, they can introduce substantial inequity into the health insurance system. It is a problem if the people who are less likely to benefit from the programs are those who may need them more.
But incentives aligned to the practice of evidence based medicine and in particular the financial challenges facing the ever increasing ordering of tests is where there seems to be significant progress. The announcement of a statewide adoption of Radport by the Institute of Clinical Systems Improvement (ICSI), a nonprofit comprising 60 medical groups, 9,000 physicians, and six payers and health plans was covered extensively at RSNA 2010 in Chicago this year and featured in this piece in Information Week "System Helps Doctors Pick The Right Tests" demonstrating a saving of $27 Million over the preceding year
During the yearlong pilot involving more than 2,300 ICSI-member physicians, ICSI saw no growth in the number of high-tech diagnostic imaging tests ordered. In previous years, the number of tests ordered grew about 8% annually...The lack of growth translates to a savings about $28 million for the year
But any discussion on incentives needs to include the issue of malpractice - liability drives behavior in the same way as incentives do (in some respects its incentive in another from). Peter Orszag opinion in the NY Times Malpractice Methodology makes the point that
The health care legislation that Congress enacted earlier this year, contrary to much of today’s overheated rhetoric, does many things right. But it does almost nothing to reform medical malpractice laws. Lawmakers missed an important opportunity to shield from malpractice liability any doctors who followed evidence-based guidelines in treating their patients.
President Obama weighed in on this issue in June 2009 when he spoke to the American Medical Association when he highlighted the "unnecessary tests and treatments (ordered by doctors) only because they believe it will protect them from a lawsuit" and as he put it
We need to explore a range of ideas about how to put patient safety first, let doctors focus on practicing medicine and encourage broader use of evidence-based guidelines
Medicine remains "more evidence-free" than should be the case:
One estimate suggests that it takes 17 years on average to incorporate new research findings into widespread practice
Addressing the issue of liability can take the traditional approach of limiting punitive damages but as Peter Orszag said "provide safe harbor for doctors who follow evidence-based guidelines" is a much better idea and one that would sit well with patients and doctors alike (I'd be interested to hear from lawyers who agree or disagree on the merits of such an approach).

There are some initial moves in this direction and a need to implement technology to help guide the treatment (as we see with ICSI) and all this would also lead to higher quality of care for everyone and possibly a new system that reimbursed based on the quality of care delivered versus the quantity of care.