Comments on: EVIDENCE-BASED MEDICINE: The Difficult But Critical Step Of Adding Cost http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/ The Policy Journal of the Health Sphere Fri, 20 Nov 2009 20:04:42 -0500 hourly 1 By: Dr Rich’s Covert Rationing Blog » Blog Archive » Former CMS Official “Admits” to Covert Rationing http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/comment-page-1/#comment-6156 Dr Rich’s Covert Rationing Blog » Blog Archive » Former CMS Official “Admits” to Covert Rationing Mon, 16 Jul 2007 13:43:56 +0000 http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/#comment-6156 [...] In my forthcoming book, Fixing American Healthcare - Gekkonians, Wonkonians and the Grand Unification Theory of Healthcare, I demonstrate how the imperative to covertly ration healthcare causes payers to bastardize evidence-based medicine. In a recent interview in Health Affairs, Sean Tunis MD, formerly Medical Director for the Centers for Medicare & Medicaid Services (CMS), goes a long way toward admitting this to be the case. [...] [...] In my forthcoming book, Fixing American Healthcare – Gekkonians, Wonkonians and the Grand Unification Theory of Healthcare, I demonstrate how the imperative to covertly ration healthcare causes payers to bastardize evidence-based medicine. In a recent interview in Health Affairs, Sean Tunis MD, formerly Medical Director for the Centers for Medicare & Medicaid Services (CMS), goes a long way toward admitting this to be the case. [...]

]]> By: The Integrative Stream » Cost and Quality http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/comment-page-1/#comment-6086 The Integrative Stream » Cost and Quality Tue, 10 Jul 2007 14:58:48 +0000 http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/#comment-6086 [...] HealthAffairs: The Difficult but Critical Step of Adding Cost [...] [...] HealthAffairs: The Difficult but Critical Step of Adding Cost [...]

]]> By: Ken Terry http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/comment-page-1/#comment-6039 Ken Terry Tue, 03 Jul 2007 17:32:55 +0000 http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/#comment-6039 I agree that, to have a real impact on spending, quality improvement and P4P programs based on evidence-based-medicine principles must consider the effectiveness of interventions relative to their cost. But, aside from the ethical issues involved, we also have to grapple with the many holes in the evidence, particularly with regard to the comparative effectiveness of various interventions. In this regard, Gail Wilensky and others have made a valuable suggestion about setting up a national comparative effectiveness research center that would receive public and private funding. In addition, more consideration should be given to using practice-based research networks for low-cost, practical clinical trials, especially in primary care. I agree that, to have a real impact on spending, quality improvement and P4P programs based on evidence-based-medicine principles must consider the effectiveness of interventions relative to their cost. But, aside from the ethical issues involved, we also have to grapple with the many holes in the evidence, particularly with regard to the comparative effectiveness of various interventions. In this regard, Gail Wilensky and others have made a valuable suggestion about setting up a national comparative effectiveness research center that would receive public and private funding. In addition, more consideration should be given to using practice-based research networks for low-cost, practical clinical trials, especially in primary care.

]]> By: John Haughton http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/comment-page-1/#comment-5885 John Haughton Wed, 27 Jun 2007 16:22:12 +0000 http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/#comment-5885 Looking at current Evidence Based Medicine improvement initiatives and P4P programs -- many do have "non-performance elements emphasized" - Don't prescribe brand name prescription meds (measured as % of generic prescriptions) sits at the top of many P4P programs. Dr. Eddy's explicit statement is on target and correct, it is important to explicitly and deliberately emphasize and de-emphasize desired behaviors to get change. In addition, making it easy to access the information about the patient and the evidence within real-time clinical workflow is critical to improvement strategies. We have found that routinely it is possible to change point--of-care behavior in a 3-6 month period (eg moving poor control A1c from 26% to 12% in a PHO; moving good control A1c from 42-57% in scattered primary care offices, controller med use in Asthma from 43 to 76% in an IPA years ago, etc) simply by getting the right questions and last values in front of the provider at the time care is delivered - right questions as those questions relevant to THAT PATIENT at the time when the patient is being thought about or seen. It is exciting to see a growing interest in getting the right information to the right spot within the clinical workflow at the right time to improve care! Looking at current Evidence Based Medicine improvement initiatives and P4P programs — many do have “non-performance elements emphasized” – Don’t prescribe brand name prescription meds (measured as % of generic prescriptions) sits at the top of many P4P programs. Dr. Eddy’s explicit statement is on target and correct, it is important to explicitly and deliberately emphasize and de-emphasize desired behaviors to get change.

In addition, making it easy to access the information about the patient and the evidence within real-time clinical workflow is critical to improvement strategies. We have found that routinely it is possible to change point–of-care behavior in a 3-6 month period (eg moving poor control A1c from 26% to 12% in a PHO; moving good control A1c from 42-57% in scattered primary care offices, controller med use in Asthma from 43 to 76% in an IPA years ago, etc) simply by getting the right questions and last values in front of the provider at the time care is delivered – right questions as those questions relevant to THAT PATIENT at the time when the patient is being thought about or seen.

It is exciting to see a growing interest in getting the right information to the right spot within the clinical workflow at the right time to improve care!

]]> By: Joseph Nicholas http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/comment-page-1/#comment-4709 Joseph Nicholas Thu, 21 Jun 2007 11:01:51 +0000 http://healthaffairs.org/blog/2007/06/20/evidence-based-medicine-the-difficult-but-critical-step-of-adding-cost/#comment-4709 Great discussion. The intellectual and financial incentives to provide more testing and intervention, regardless of value, will prevent any significant cost containment- unless there are P4P measures that retard the use of low value (or harmful) practices. Pay for non-performance is probably more important that Pay for performance, both in terms of spending and health outcomes. Great discussion. The intellectual and financial incentives to provide more testing and intervention, regardless of value, will prevent any significant cost containment- unless there are P4P measures that retard the use of low value (or harmful) practices.

Pay for non-performance is probably more important that Pay for performance, both in terms of spending and health outcomes.

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