Critical paths a key to better care, bottom line

Develop your own with local input

If you’re looking for ways to improve patient care and control costs, developing critical pathways may be the answer you need.

Critical pathways have been somewhat of an anathema to many physicians who may have viewed them as "cookbook medicine" that was crammed down their throats by HMOs. But some practices are finding that critical pathways help them track costs, improve patients care, and take a proactive stance with managed care.

"From the beginning to the end, it helps to better guide patient care," says Rita Graves, administrator of Sandhills Physicians Inc., a Fayetteville, NC, physicians organization and its community health plan, Doctors Direct Health Care.

The organization is in the process of completing 60 critical pathways.

Pathways are written documents that include step-by-step guidelines for treating a particular condition or disease. They can be attached to a chart or come to a physician for review when a patient presents with a particular diagnosis.

"What has happened in the past is that HMOs have come up with critical pathways without the help of physicians and foisted them on physicians without getting their input," says William J. DeMarco, MA, CMC, president of DeMarco & Associates, a Rockford, IL, health care consulting firm.

But when physicians have input into the development of the guidelines, they can be a boon to their practice. For instance, in Madison, WI, where 80% of the population is covered by HMOs, the majority of HMOs are physician-owned and operated, DeMarco says.

"The guidelines are phenomenal because physicians have had adequate input. It’s a good example of what you can do at a local level," he says.

Sandhills Physicians created pathways specifically for its new community health plan, but has received interest from managed care plans as well. "Managed care organizations have expressed an interest in our ability to do this. What they have found is that it’s very difficult to get compliance nationwide. They find ours very attractive," Graves says.

When managed care organizations look at a group of physicians and see that they are taking steps to improve care and cut costs, the physicians benefit when they are negotiating contracts, she adds.

Large payers may have their own protocols but often the physicians are not aware of them, Graves says. "Most managed care payers use the standard protocols. What we’ve done is streamline that for our own community."

Critical pathways help you keep costs under control while giving a comfort level to the practitioner that there is no lessening of quality of care, says Mike Boguszewski, manager at Hamilton HMC, a health care consulting firm in Minneapolis. "Critical pathways enable physicians to see that they can standardize and use low cost options without jeopardizing the overall quality," he says.

In addition to saving money, pathways also help you identify the most effective but cost-efficient courses of treatment or decision. They allow a comparison among the various ways by which a certain disease or condition can be treated from both a quality and cost perspective, he adds.

Just the mere practice of developing critical pathways can generate savings by helping your practice identify supplies or devices that can provide the same functionality at a lower price and take advantage of volume discounts from vendors, Boguszewski says.

In an orthopedic practice, some surgeons may be using a prosthetic device that costs less than others but works just as well. Your practice may save money by switching to the lower cost item and save again by asking the manufacturer for volume discounts.

How to save money

Boguszewski gives this example of how following a critical pathway can save you money:

Historically, when a patient comes in with a diagnosis of suspected hormonal deficiency, the physician has blood drawn and orders about 25 tests. A critical pathway might specify the physician to order only four or five tests that would confirm the most probable diagnoses. If the results of those tests were negative, the pathway would specify a second and third tier of tests. Some patients still would have to have all 25 tests, but for many patients, their problem would be pinpointed with the first few tests.

"Maybe 60% of patients need only the first tier, and 80% need only the first and second tiers. When you’ve treated 1,000 patients, you’ve made significant cuts in the number of analyses and cut down overall on lab charges," he says.

As costs and charges change over time, you may see bigger or smaller savings. "In the end for all 1,000 patients, everybody ultimately gets the proper treatment, and if it’s done right, not much time passes," Boguszewski adds.

However, there must be a mechanism for exceptions to the pathway. For instance, if you’re treating pediatric patients or other people who are sensitive to having multiple needle sticks, you may have to decide whether the cost savings is a good trade-off with an unhappy patient, he explains. "Physicians have to remain advocates for their patients and have the flexibility to divert from the pathway when they feel there is a justifiable reason, whether it’s medical, psychosocial, or other."

On the other hand, you need to monitor the exceptions, he points out. The danger is that if everybody is making exceptions for their patients, you’ve wasted your time creating the pathway.

Here s a list of some changes you may need to make in order to ensure your pathways work:

- Create new contractual arrangements with vendors.

- Redesign some of your procedures or operations involving nursing or ancillary support staff.

- Establish different relationships with local support such as home health therapy or medical equipment providers.

- Conduct specialized training or inservices for your staff. For example, if a physician has never used the prosthetic device your pathway specifies, he or she may not be comfortable with it.