IMPROVING WISELY: COLLABORATION HELPS IDENTIFY, CUT HEALTHCARE WASTE
By Vanessa Salvia
In the elegant Presidential Ballroom of the Gaylord Opryland Resort in Nashville, Martin “Marty” Makary, MD, addressed American College of Phlebology’s 32nd Annual Congress attendees eager to hear his message about how the program Improving Wisely is helping to reduce waste in healthcare.
More than 1,200 registrants, guests and exhibitors heard the John Hopkins surgeon, author, and educator explain that the highly touted partnership between the Robert Wood Johnson Foundation and Johns Hopkins University School of Medicine provides physicians with an individual data report outlining their performance on quality measures using Medicare claims data.
He said the Improving Wisely program is highly effective. “It’s powerful, it works, it’s been validated.”
Dr. Makary practices surgical oncology and advanced laparoscopic surgery at Johns Hopkins Hospital in Baltimore, Maryland, and is a professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. In 2014, Health Magazine voted him one of the 20 most influential people in healthcare. Dr. Makary’s new book, “The Price We Pay: What Broke American Health Care and How to Fix It,” is available now from Bloomsbury Publishing.
In October, following significant input from the ACP, the Improving Wisely Quality Collaborative team at Johns Hopkins University began doing a deep analysis of Medicare claims data, specifically around venous ablation procedures.
Improvement among outliers in this project, those whose data lie an abnormal distance from other values has been shown to help because of three primary reasons: Outliers may be unaware that they are outliers; no one wants to be an outlier; and sharing the results in a confidential, peer-to-peer manner is an effective way to engage physicians in changing their patterns.
Starting in November, all physicians who performed 10 or more endovenous thermal ablations in 2017 in the United States began receiving their confidential individual data report notifications via mail.
PUTTING THE ORGANIZATION
AT THE FOREFRONT
During the conference attendees saw a presentation on an analysis of the overall national data. A paper will also be drafted for publication that will report national results. Participation in this program represents one of the ACP’s major investments over the 2018 and 2019 years. This effort puts the ACP and its members at the forefront of evidence-based vein care.
In an interview before his speech, Dr. Makary said that one of the main barriers to healthcare improvement has been the massive expansion of the middle man. “The administrative waste and clinical waste is unprecedented and represents a massive bubble which will lead to a massive financial crisis in the system,” he said.
He pointed out that one in five Americans today has medical debt in collections. One in two patients with stage 4 breast cancer are being harassed by debt collectors at the end of their life. Healthcare is officially the number 1 industry in the United States, with one in five people working in the industry. At one facility, the price for a single procedure done by the same surgeon can increase by 50 percent in one year. These high costs and wide variability are crushing many American families.
“I think we all believe that a business model is necessary in healthcare, but nationwide what we have is a giant mess, a system that’s too expensive, unaffordable and riddled with waste,” he noted. “This message resonates very well with practicing physicians because, generally speaking, busy doctors, especially busy doctors who are taking care of patients every single day, are aware that there are shenanigans or money games that are part of the business of medicine that are accepted, that are part of the way that business is conducted, but they may not know exactly what those games are.
“So my task in the talk [during the Nov. 9 address to the Congress] is to break down exactly the current state of the business of medicine, how medicine has lost its mission and to highlight the heroes and the disruptors who are leading the effort to restore medicine to its heritage of taking care of patients regardless of their ability to pay, while at the same time believing that we have to reward clinicians, doctors and nurses well to attract the best people.”
IMPROVING WISELY ADDRESS
Through a series of engaging anecdotes about his Egyptian mother’s skepticism, presidents George Washington and James Garfield, and American painter Thomas Eakins, Dr. Makary effectively made his point that both the problems with and the solutions for effective, affordable healthcare are deeper than what they seem on the surface. Much of this stems from the process of reporting and measuring.
“We spend $15.4 billion on the process of reporting quality data to the government,” Dr. Makary said in his speech. “That’s the equivalent of every physician in the U.S. having half an FTE. We are playing a massive game of reporting things, and the question is, is it making healthcare better?”
What physicians have been measuring has created a massive burden. Not only that, he says, but physicians have also probably not been measuring the right things. One example he gave was that of measuring complication rates.
“Someone comes in to see us and we do something, then we look at the complication rate of that procedure,” he explained. “The complication rate of most procedures is very low. Take knee replacement, with a complication rate of three tenths of one percent. Is the surgeon with a complication rate of four tenths twice as bad? No. Orthopedic knee surgeons are saying that about 20 percent of all knee replacements are unnecessary. So, we’ve been measuring complication rates, but we have not been measuring the appropriateness of care.”
Ten years ago, physicians prescribed 2.4 billion medications. Last year, the number was 4.7 billion. Did disease double? No, Dr. Makary said. Instead, we have a crisis of appropriateness. The two biggest drivers of high healthcare costs are clinical waste and administrative waste, and the Improving Wisely program is helping to root out both of these.
LOOKING FOR PATTERNS AND OUTLIERS
Improving Wisely taps the expertise of people who practice in a specialized area who share information to help identify patterns. One example that Dr. Makary gave is that experts assert that after a breast lumpectomy, there should not be more than a 20 percent re-excision rate. But after examining actual re-excision rates, they found some that are 40 to 50 percent.
The program compiles the names of these physicians and the cities where they practice. There is no punitive element to participating in Improving Wisely, so the physicians who exhibit wide unwanted variation are not punished. But they are given a report that shows where they place in relation to other physicians.
Just being told that they are outliers resulted in a reduction in their re-excision rate by half. Why? Because the culture has started changing after they were made aware of the significance of their variations. The program cost $150,000 to implement but saved millions after showing improvement in 83 percent of outliers.
Dr. Makary said the Improving Wisely program is highly effective. “It’s powerful, it works, it’s been validated and it’s an alternative to the heavy-hand approach to quality measures that payers and the government have been proposing.
“And personally, as a busy surgeon, the reason that we’ve developed this project nationally is that we felt there was a big need to allow physicians to author this process entirely and we were concerned that payers and the government were applying their quality measures in a way that didn’t truly capture what was important to patients and that is the appropriateness of care, and it had a punitive approach and humiliation approach in making the data public.”
Dr. Makary closed his speech with a clip of “The Resident,” the medical drama television show that was inspired by his memoir, “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” and images of paintings showing the transformation in operating room procedures.
In the clip, the narrator says, “All we want to do is help our patients but what they don’t teach us in medical school is there are so many ways to do it.” In Aiken’s 1875 painting, “The Gross Clinic,” the surgery is performed in an unhygienic environment, and is notable for its drama in the depiction of the surgery. Aiken painted a much more civilized scene in 1889 in his painting “The Agnew Clinic.” In that, the surgery theater is lighter, brighter, hygienic and more collaborative.
As Dr. Makary aptly noted, show medicine learning from its mistakes and improving, which is what Improving Wisely is all about. VTN