How one doctor proved his worth with managed care’

Protocols bring better care, cost savings

It was a familiar scenario: The vice president of a health plan asked Toledo, OH, urologistDan Murtagh, MD, to accept a deeper discount. Murtagh countered that he and his partners provided better than average care and therefore deserved higher fees. The vice president just shrugged.

Murtagh needed proof of quality — and now he has it. By creating protocols and monitoring their use in his practice, Murtagh and his partners saved about $400,000 in health care costs in one year for metastatic workup in prostate cancer. He demonstrated that standardizing care could eliminate unnecessary tests while maintaining a high level of patient care.

Murtagh expects further savings from that and other protocols, and he’s preparing to spread his methods to other urologists around the country. (See editor’s note for more information.)

"It dawned on me that we had no way of communicating with [the health plan vice president] or any other insurance company in an objective way about the quality care we were delivering," says Murtagh. "If it’s going to be this competitive, we’re going to have to be able to differentiate ourselves in the arena of cost, quality, and outcomes from our competitor."

Murtagh’s foray into quality improvement began with a course, "Advanced Training Program in Clinical Practice Improvement," taught by Brent C. James, MD, executive director of the Institute for Health Care Delivery Research at Intermountain Health Care in Salt Lake City.

Developing practice protocols "is a means for physicians to collaborate together in the interest of better patient care," says James. "That is what will guarantee survival in a managed care marketplace."

The next time a managed care executive asks Murtagh for a deeper discount, he’ll have outcomes data and cost savings to show them. Murtagh believes that information will be a powerful negotiating tool.

Here’s how Murtagh began his protocol-based improvement program:

1. Select a procedure and conduct a literature search.

What is the greatest opportunity for improvement? "Inappropriate variation is your enemy," says James, referring to variation in practice that isn’t related to patients’ needs.

Murtagh realized that when he conducted a metastatic work-up for prostate cancer, the diagnostic tests he ordered varied from patient to patient and from those of his colleagues. He had no way of knowing which tests were most useful and which were ultimately unnecessary.

Murtagh convened a meeting with his partners, hoping they could agree on one protocol. After 90 minutes of debate, he realized he needed research-based data to support his hunch that many tests were unnecessary.

2. Develop protocol with input from physicians.

Based on the medical literature, Murtagh proposed a pared-down patient work-up. Instead of ordering a complete battery of tests for all patients (chest X-ray, acid phosphatase blood test, SMA 1260 blood profile, CT Scan or an MRI, and a bone scan), the new protocol stratified patients into risk groups and called for a bone scan and/or acid phosphatase test for those with low and moderate risk.

He reconvened a session with his partners and reached a consensus. Although not all supported standardization, they agreed on the steps for a protocol.

"It frankly builds up a little bit of comradery," he says of the process. "It was the first time in 10 years that we sat down and discussed how to work up a patient."

3. Emphasize that the protocol is voluntary.

Murtagh posed this question to skeptical colleagues: "[The protocol] may not be perfect, but can you live with it for six months while we work up the data?"

He stressed that protocols cannot supplant physician judgment. "If you want to vary, go ahead and vary, and we’ll track that variance," he told them.

Initially, the group’s physicians varied from the protocol with about 30% of patients. One physician varied as much as 70%. When it became clear that the additional tests didn’t add value to the work-up, variation dropped to about 15%.

In general, adherence to a protocol can range from 60% to as high as 96% with simple and highly accepted protocols, says James. Adherence never reaches 100%.

"If anybody ever does [reach 100% adherence] it means either they’re lying on the data form or you have somebody who’s not really caring for the patients," says James. "They’re letting the computer care for the patient and that’s not acceptable."

4. Create a simple form for ease in following the protocol.

Murtagh developed a form that could be used as a progress note, to collect data, and to order tests. "All they had to do was to check a box and sign their name, and the protocol would be instituted," he says.

If physicians chose not to follow the protocol, they checked a box saying they deviated, wrote out the tests they wanted to order and the reason, and signed the form.

Murtagh uses color-coded strips on the bottom of the forms to flag which patients are on a protocol. When the patient checks out after a visit, the receptionist enters the name into the computer indicating he or she is on a protocol, orders the tests, and places the form on the front of the chart.

The form remains on the front of the chart until the results are available. The receptionist also makes a copy of the form to send to the statistician hired by Murtagh to collect and evaluate data on the protocol.

Simplicity is a virtue in protocols, says James. "If they fail, it’s [often] because they’re operationally difficult to use on a day-to-day basis," he says.

5. Calculate cost-savings and clinical impact.

Murtagh needed a year’s worth of data to make a statistically sound judgment about the changes in metastatic work-up for prostate cancer, and he wanted quarterly reports for feedback. He hired a statistician from a local university to conduct the data analysis using the forms he collected.

For the protocol study, each physician in the practice had a confidential identification number. Charts showed how many times each physician deviated from the protocol, and how many deviated tests were ordered per doctor. The data also showed how many of those additional tests produced abnormal results.

Did the extra tests detect more patients with positive lymph node involvement? The surprising result: In a year, none of the additional tests produced abnormal results.

"It’s the right thing to do for your patients," Murtagh says of the protocol. "Why put them through all these tests and scare them and concern them when they’re not really necessary?"

By reducing the number of tests, Murtagh says he saved about $1,000 per patient. After the results of the outcomes study and a further literature review, Murtagh is revising the protocol to eliminate all diagnostic tests for low- to moderate-risk patients, which will lead to further cost savings.

6. Evaluate use of the protocol.

When Murtagh presented the results of his outcomes study to his colleagues, he asked, "Can we continue to order these tests on patients when we know they don’t add any value, and they’re wasting money?"

Even the physician who had been most resistant to the protocol was swayed. "That to me was the greatest success of this project," says Murtagh. "It’s changing physician behavior based on data."

[Editor’s note: Murtagh plans to provide protocol forms to other urologists, collect their data for analysis, and provide reports. For more information on the protocol project, contact Dan Murtagh, Genito-Urinary Surgeons, 3500 Executive Parkway, Toledo, OH 43606. Telephone: (419) 531-8558.

For more information on the Advanced Training Program in Clinical Practice Improvement, contact Eve Watson, Coordinator, Intermountain Health Care, 36 South State Street, Salt Lake City, UT 84111. Telephone: (801) 442-3623.]