Variations in treatment cause waste, inefficiency

Plan takes twofold approach to consistency in care

Everyone knows that inconsistencies in health care can adversely affect patient outcomes, waste time and resources, and ultimately cost the consumer, the provider, and the health plan money.

The staff at Highmark Blue Cross Blue Shield in Pittsburgh is working to do something about it.

"Health plans have extensive patient data and a lot of opportunities to improve care and lessen the degree of variation in practice patterns that affect health care quality, waste, and cost inefficiency," says Don Fischer, MD, MBA, a medical director for the insurer.

Variations in care are caused by physicians’ lack of knowledge of the latest treatment techniques, lack of information that effective care was delivered, lack of an internal system to assure that the care was delivered, and failure of patients to follow the prescribed plan of care, he says.

"The health plan’s role can be valuable in achieving the goal of reducing unwarranted variation and providing the best value for the health care dollar. Cooperation among all the stakeholders is necessary if we are going to be successful in giving the patient the best care and an opportunity to achieve the best outcomes," he adds.

Under Fischer’s leadership, Highmark has launched a twofold approach to eliminating practice variations and improving the quality of care for its members — one dealing with members and the other with physicians.

Highmark’s integrated condition management program (formerly known as disease management) uses health coaches who work with patients to reinforce physicians’ messages with the highest risk patients, to motivate them to comply with their plan of care, and to help them understand their condition.

The SMART Registry provides physicians feedback on their patients, their conditions, and compliance with effective care options such as recommended tests and medications, and practice-level reports that compare physicians to their peers in terms of quality indicators.

"They’re not report cards. It’s what we can do to help with process improvement. In the long run, we have found that this is the best way to save money," Fischer says.

The vast majority of physicians wants to do the right thing and know the right thing to do but don’t have processes in place to see that it is done in a consistent manner, he says.

Highmark’s aim was to develop programs that recognized the physician-patient relationship as critical in treating people with chronic diseases and to recognize that many patients have multiple comorbidities.

"We didn’t want just a cookie-cutter program for patients," Fischer says.

Employers who are concerned about increasing health insurance costs are helping drive the focus on eliminating variations, Fischer says.

"In the employer world, unwarranted variation suggests a process out of control, the implications that quality is not optimal, and that dollars are being wasted," he says.

Fischer has long been interested in eliminating unwarranted variations in practice patterns. He joined Highmark in mid-2001 after practicing at Children’s Hospital in Pittsburgh, part of an academic medical center. "I made the leap to come to a health plan because it gave me an opportunity to affect a much broader range of patients," Fischer says.

Fischer outlines three types of variation in care:

Effective guidelines variation. This occurs when there is scientific evidence that a certain procedure should be done for a certain condition and it’s not being done or being underutilized. An example is dilated retinal eye examination for diabetics.

The SMART Registry is Highmark’s attempt to address this variation.

• Preference-sensitive care. This occurs when a patient has multiple options that may have equal validity. For instance, in the case of prostate cancer, patients may consider radical surgery, radiation treatment, or watchful waiting.

The health plan’s health coaches give the patients unbiased information about all the options so they can choose what suits them best.

"It moves from the paternalistic system where the physician made all the decisions, and many times, the decisions were based on where the doctor trained and who trained them," Fischer says.

• Supply-sensitive variations. This is based on what resources are in the community. For instance, a city with more cardiologists may have more cardiac procedures being done. If there are more intensive care unit beds in a community, patient are more likely to spend the last part of their life in the ICU.