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Variance: Clinical Causes & Overuse


Clinical Causes & Overuse

q_iconVariance in health care manifests in cost and patient outcomes. Large variations in healthcare costs have become a central focus of research in the United States, with unnecessary costs resulting in as much as 30% waste. Started 20 years ago by Dr. Jack Wennberg, the Dartmouth Atlas of Health has repeatedly found that variation in provider practice patterns is driving those spending differences, not the level of illness among patients. However, a study by the Center for Studying Health System Change published in Medicare Care Research and Review, found that overall variation in how sick people are in different geographic regions, or even within a region, accounted for as much as 75% to 85% of the difference in spending between high-cost and low-cost areas. Analytics of variation suffer from risk adjustment methods.

New approaches to measuring variance are confirming many dramatic concerns for American health care. A study published in the Journal of the American Medical Association (JAMA) in 2013 found that the costs of total hip replacement surgeries ranged in both top-ranked hospitals ($12,500 – $105,000) and non-top-ranked hospitals ($11,100 – $125,798). Another example is a cohort study of physician variation in the management of low-risk prostate cancer patients. Case-adjusted rates of observation rather than treatment ranged from 4.5% to 64.2%, with analysis of physician billing patterns. The physician authors from the University of Texas, MD Anderson Cancer Center call for public reporting of physicians’ cancer management profiles. Significantly, one of the four (4) major areas of focus for standardized outcome metrics is prostate cancer (International Consortium for Health Outcomes Management).

Of course, McAllen, Texas (where we had already given expert testimony in Federal Court about one specific peer review clinical debate), became the poster child for overutilization after Dr. Atul Gawande painted an unflattering portrait of the city’s physician and hospital practices in a New Yorker magazine profile. The idea eventually received the official imprimatur of the Institute of Medicine, which agreed that overall spending could be slashed by $690 billion a year if every healthcare system delivered care with the efficiency of the lowest-cost providers.

Success Story

Our first external peer review engagement in Texas was to answer the question about the competence of a single neurosurgeon performing spine surgery. The review was initiated by the re-insurer for a major hospital system because of extensive medical malpractice cases disclosed in a deposition and the basis for a massive surcharge for every hospital in the system – unless the problem was evaluated and, if necessary, solved. Initially, there was no clear pattern of any clinical competence issue with the surgeon. However, after extensive external peer review, there was a disturbing pattern of unnecessary spine surgery in workers compensation patients who were coming to both neurosurgeons at this hospital.

Clinical performance problem identified with analytics

One of our success stories is uniquely compelling studying variance caused by unnecessary spine surgery in a hospital in New England. A neurosurgeon practicing at our client’s hospital moved his practice to another nearby hospital due to a nursing strike. After several years, the other hospital revoked all of the surgeon’s privileges, and he returned to our client and continued his practice there exclusively. In response to questions by our client, the other hospital would not give any indication of the reason they had terminated his privileges. So our assignment, as often, was there is a needle in this haystack – see if you can find it.

Clinical performance problem solved with prescriptive knowledge solution

We instituted our usual protocol and, with the assistance of three (3) distinguished neurosurgeons, determined that the neurosurgeon was performing extensive unnecessary spine surgery. The difference with Quture is that we not only identified the problem, we instituted a rigorous, prospective clinical protocol that proscribed precise radiographic evidence of the spine lesion necessitating surgery. We also precluded use of MRI studies at the facility in which the surgeon had a family interest. Our client was able to continue to experience revenue from the neurosurgeon, but only where there were appropriate clinical indications for the spine surgeries. Fortunately, by the time state regulators completed their independent evaluation years later, our client was able to demonstrate that the unnecessary variances in care had been solved.

We are not only an analytics company; we have extensive experience in hundreds of healthcare organizations determining root causes and, where possible, changing behavior with prospective clinical patient safety and quality management CLINICAL KNOWLEDGE SOLUTIONS. Significantly, most unnecessary spine surgery in our experience is on young patients with excellent outcomes and where the patient (and the patient’s tort lawyer) received what they wanted.

Billing codes were of no value in this analytics process.