What about bending the quality curve?
May 2, 2012 — A recent study showing that the adoption of information technology by physicians did not reduce the number of procedures performed was seen as worrisome both by the popular press and by some of the many health care observers for whom the paramount objective of incentivizing providers to embrace health technology is to cut the costs of care.
As noted in a recent article in The New York Times, “Policy makers on both sides of the aisle see rising health care costs as the central threat to household budgets and the country’s fiscal health.” With costs treated as the enemy, the prime target has become “overutilization” of medical care, caused both by patients who supposedly devour medical care promiscuously and by doctors who over-prescribe expensive tests.
With this mindset, it’s not surprising that the article reported as a happy development that the growth in health insurance plans that require people to pay more out of pocket “means thousands of consumers with an incentive to think twice about heading to the doctor.”
Similarly, another recent article, this one reporting on a study that found that doctors using electronic medical records ordered more imaging procedures than doctors who used paper records, was cost-obsessed, having only one throwaway line in the entire article from the study’s author that electronic medical record “can improve the actual practice of medicine.”
It seemed to us that the question of quality of care was taking a back seat to questions of cost of care — if it got a seat in the health care policy car at all. And it also seemed like the cost-cutting reformers didn’t want to acknowledge either that underutilization of health care services is a problem, or that electronic medical records could be a tool by which doctors would be able to identify and rectify situations where their patients were getting less care than they needed.
We thought this enormous hole in the health care debate deserved to be reported on.
But further inquiry into the study — and the responses to it — reveals more far-reaching implications: according to several researchers, the overriding focus on cost-cutting has subordinated the goal of improving access to and quality of care, and has ignored entirely the phenomenon of underutilization of appropriate medical interventions.
What about underutilization?
The study, published last month in the journal Health Affairs, used survey data from the National Center for Health Statistics to measure the usage of digital imaging, such as CT scans and MRIs, across a broad sample of doctors and patients. It found that physicians who had access to digitized imaging results — through an electronic health record (EHR), for example — were significantly more likely to order imaging tests than those who did not.
Among health policy experts and some members of the Obama Administration, the study is alarming because it calls into question one of the central assumptions undergirding much of the Administration’s health policy: that its reform efforts will yield significant cost-savings by helping doctors to reduce the frequency with which they prescribe various medical procedures.
Over the last decade, several studies have found that there is significant overuse of medical imaging in the United States, with some researches estimating that up to a third of all CT scans are duplicative or unnecessary. EHRs and other forms of health IT have been widely touted as having the potential to reduce long-term costs by discouraging unnecessary and potentially harmful treatments, and in 2009 the Health Information Technology for Economic and Clinical Health (HITECH) Act — part of the American Recovery and Reinvestment Act — authorized up to $29 billion in to incentivize the adoption of EHRs.
“A lot of the conversation about the benefits of health IT has focused on its ability to decrease test-ordering,” said Danny McCormick, an assistant professor at Harvard Medical School and the lead author of the study, “but, so far, that does not seem to have happened.”
McCormick said that he believes that health IT may have the potential to reduce wasteful care, which he called an “admirable goal.” But he also said that, if properly implemented, it has much broader potential: to increase the overall quality of care, not only by eliminating some harmful tests and procedures, but also by helping doctors ensure that they deliver medically valuable care that they currently fail to provide.
“There is a tremendous amount of overutilization, and that’s where the conversation has been, but there is also a tremendous amount of underutilization,” McCormick said. “If we are serious about improving the quality of care, in some settings that will imply fewer tests. In other settings, some people are going to be getting care that they are not getting now. That makes the question of overall costs a lot more complicated.”
Trying to bend the cost curve down, not the quality curve up
McCormick pointed to several studies that have shown that, on average, patients receive far less care than would be recommended by basic medical standards. Along with several other health policy experts, he said that the policy constructed around health IT — and more broadly around issues of payment, delivery, and access — has largely subordinated the goal of improving quality and access to the goal of reducing costs.
Rosemary Gibson is a health policy expert and the author of a book that warns about over-testing. She said that reducing overutilization is essential because unnecessary care can have serious, harmful effects, but she also said that it is improper not to address underutilization at the same time. She has been disappointed in the Obama Administration’s efforts, she said, because “what’s best for patients has taken a back seat to what is politically feasible in terms of cutting costs.”
Indeed, some of President Obama’s advisors have framed the goals of health care reform exclusively from the perspective of the need to cut costs, as opposed to the need to increase access of quality of care. David Cutler, a professor of economics at Harvard who served as a senior health care advisor to President Obama, has written that the “true measure of health care reform’s success is whether it drives down medical costs over the long term.”