M a t h e m a t i c a I S S U E b r ie f Policy Research TI M EL Y
INFOR M ATION
FRO M
M ATHE M ATICA
Improving public well-being by conducting high-quality, objective research and surveys
DECEMBER 2010 Number 2
topics in health care effectiveness
Using Comparative Effectiveness Research: Information Alone Won’t Lead to Successful Health Care Reform by Dominick Esposito, Arnold Chen, Margaret Gerteis, and Timothy Lake
H
ealth policy experts argue that better information on what works in the health care system is key to providing better value and improving patient care. To this end, the American Recovery and Reinvestment Act of 2009 allocated $1.1 billion for rapid expansion of the nation’s capacity for comparative effectiveness research (CER). Yet even ardent policy advocates for CER have been reluctant to anticipate large savings from simply discovering better evidence of clinical effectiveness.1 At the Congressional Budget Office, Peter Orszag noted, “. . . the financial incentives for both providers and patients tend to encourage the adoption of more expensive treatments . . . even if evidence of their relative effectiveness is limited.”2 If CER is to facilitate health care reform, science must answer many questions 3–6 about how to get CER into use at the point of care, focusing on knowledge translation, provider incentive reform, delivery system transformation, and consumer engagement. This brief highlights opportunities to develop these critical areas.
Realizing the Potential Although recent attempts to improve the U.S. health care system have been numerous, they have also been largely unsuccessful. Yet some promising models exist. Clearly, developing better evidence on the effectiveness of medical treatments and procedures is the cornerstone of any improvement. But the potential of CER can only be realized by simultaneously addressing how that information is disseminated, implemented, and interpreted. Yet even when armed with good information,
A B O U T THIS SERIES
This brief is the second in a series from Mathematica’s Center on Health Care Effectiveness highlighting issues that can help inform today’s difficult health care decisions. Learn more about the center’s work at http://chce.mathematica-mpr.com.
providers may not act if health care incentives don’t align. The delivery system isn’t structured to rapidly absorb and adapt to new information to support the changes being implemented. Comparative effectiveness research can help improve these critical elements of health care reform and better demonstrate how the elements fit together to improve health outcomes and increase the value of each dollar.
Knowledge Dissemination A top priority for CER identified by the Institute of Medicine’s CER Priorities Committee is to “compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.”7 This emphasis recognizes that even superlative evidence on the relative effectiveness of diagnostic or therapeutic interventions cannot benefit patients or the health care system if clinicians remain unaware of it. Thus, a prerequisite to using CER in health care reform is dissemination of findings to providers.8,9 Despite much work in this field, questions remain regarding what facilitates knowledge transfer and how its attributes vary by clinical audience and context.10 A related question is how best to synthesize knowledge into usable formats, such as clinical practice guidelines, to speed effective dissemination. Some long-standing approaches to knowledge translation have proved unsuccessful. For example, traditional continuing medical education has had little effect on clinical practice or patient outcomes.11 Likewise, printed materials (even authoritative guidelines) often have minimal impact on medical care.12,13 Nonetheless, more innovative educational activities, employing better needs assessment and
interactive methods, can alter clinician behavior and even health care outcomes.14,15 Researchers have identified a broad array of interventions effective at achieving practical learning and real-world practice change in health professionals.16,17 These approaches draw on professional community resources (such as academic detailing18 and engagement of opinion leaders19) as well as practice-based strategies (such as computer-generated reminders, protocols, decisionsupport systems, and clinical database-driven audit and feedback methods20,21) and multifaceted educational interventions.22,23 These new approaches to knowledge translation show promise, but research will need to clarify when and under what circumstances these techniques are most effective at facilitating the appropriate clinical use of new CER findings.
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it.”24 Upton Sinclair
Provider Incentive Reform Sinclair’s reflection is as relevant for today’s clinical practitioners as it was for factory managers at the turn of the 20th century. The redesign of provider incentives in today’s health care system is a critical part of the reforms needed to enhance use of CER in medical care. Recent research and operational experiences in provider payment reforms can provide us with important lessons for how to put new clinical evidence into action. The current system views health care providers as the agents of patients who on their own do not have the knowledge and skills to provide for their own health. However, without proper incentives, providers might not fulfill the role desired by their patients or deliver care that is in patients’ best interest. Under this framework, payers must devise incentives for providers that deliver the correct economic signals to reward fulfilling this role.25–27 Recent developments in behavioral economics suggest an even more complicated environment wherein providers might not respond to incentives in purely rational ways, with responses predicted as much by psychology as economics.28 Nonetheless, most policymakers believe that the predominance of fee-for-service (FFS) reimbursement in today’s health care market encourages excess service use, with little or no recognition of differences in the value of specific services for patients. Research shows that when providers receive compensation on an FFS 2
basis they tend to order more tests, consultations, elective procedures, and hospitalizations. Conversely, when payments are bundled through capitation or other methods providing financial risk for providers, service use tends to be constrained.29–33 Yet, like FFS reimbursement, traditional capitation provides little explicit recognition of the varying value or effectiveness of different services, shown by CER. As policymakers’ interest in value-based purchasing grows, a variety of strategies are emerging to enhance provider incentives for greater use of CER. For example, direct incentives can increase the use of effective services or limit lower-value services. These include new payments for previously unrecognized high-value services, such as added fees for care coordination under patient-centered medical homes34 or rebalancing payment levels between higher- and lower-value services.35 They also include pay-for-performance approaches, with bonuses or penalties applied based on rates of delivery of high-value or recommended services.36,37 Nonfinancial incentives include feedback to providers on how they compare with their peers in use of CER and delivery of proven effective services.38 New rewards for improved patient outcomes can also provide indirect, yet powerful, incentives for use of evidence-based services. For example, episode-based payments can provide incentives for adoption of high quality and efficient care processes during specific clinical episodes of care through either incorporation of evidence-based services into the payment bundling and/or incentives to achieve better outcomes during particular episodes.39,40 It is also possible to construct incentives for accountable care organizations to promote adoption of evidence-based medicine across a wide variety of services and clinical conditions.41–43 Policymakers and practitioners face important design and implementation challenges as they adopt provider incentive reforms. For example, with the growing number of CER findings, devising incentives without overwhelming providers with a confusing mix of signals will require careful balancing of priorities. Moreover, as new evidence emerges, identifying the optimal way of revising incentives—including the strength and risk–reward tradeoff of the incentive—will prove challenging. In addition, incentives can be direct or indirect as well as financial or nonfinancial; how to use disparate incentive structures simultaneously should be explored with rigorous research in a variety of settings and populations before widespread implementation. Lastly, recent evidence confirms the complex interplay of factors that can determine local payment rates and the challenge of developing consistent incentives.44 These options underscore the challenges in using
payment reform to promote evidence-based clinical decision making. The complexities highlight the need for further research to clarify the appropriate reform of provider incentives to promote optimal use of CER.
Delivery System Transformation After more effective ways to inform clinicians of CER and provide incentives to use better clinical evidence in their decision making are identified, better processes to use CER at the point of care will be required. Past efforts show that the clinical workplace can have a powerful influence on how clinicians practice. Researchers and policymakers recognized this during the 1990s era of managed care—when health insurers began using administrative techniques such as reminders, case managers, and care protocols to promote increased use of evidence-based practices among providers.45 Many of these activities suffered from a lack of careful scientific appraisal before widespread implementation, making it difficult to interpret whether the managed care intervention achieved the desired long-term results. Moreover, many providers believed there was more “hassle factor” than evidence-based medicine in managed care’s early efforts to reduce costs. History suggests that effective delivery system transformation occurs over time with iterative, evidence-based changes. The transfer of research findings into practice can be an unpredictable, slow, and haphazard process,46 although there are other examples in which studies were followed by rapid changes in practice.47 Further research on clinical delivery systems will be needed to identify the processes that improve the fidelity of health care interventions and speed the transition from research findings to clinical practice. Without such an understanding, efforts to implement CER findings might be ineffective in changing decision makers’ behaviors; indeed, such efforts might create unexpected problems adapting and applying the new evidence. Nonetheless, implementation research has identified promising techniques that might transform the clinical workplace to promote and sustain rapid introduction of CER findings into practice.48,49 Clinicians’ approach to storing and accessing patient information is one area in which health care delivery is rapidly transforming, in part due to large federal investments.50 Although challenges such as meaningful use and interoperability of disparate data systems are yet to be worked out, greater use of health information technology (HIT) offers the opportunity to improve quality of care through a variety of means, including increased care coordination among providers.51 HIT applications, such as electronic health records and computerized physician 3
order entry, have had positive effects on quality of care and cost savings.52,53 The potential benefits from these technologies might be magnified when combined with more advanced information technologies, such as decision support systems and point-of-care clinical reminders, which can be informed by CER.51 Basic quality improvement techniques, such as checklists, have demonstrated positive results in delivery system transformation.54 More sophisticated quality improvement approaches to implementing evidence-based practice have also been shown to yield dramatic benefits for some groups of patients.55,56 Such techniques can reduce unwarranted variations in clinical practice and health care costs as well as improve clinical efficiency and patient outcomes. However, research will be needed to determine how best to combine these delivery system techniques with knowledge translation and incentive reform to promote CER-guided advice to patients.
Consumer Engagement Efforts to promote quality and efficiency in the health care system will not gain much traction until consumers—the end users and ultimate beneficiaries of the system—are better informed and engaged in the issues at stake and the tradeoffs to be made with their care. Greater patient use of CER in decision making at the point of care requires better understanding of consumers’ preferences and incentives, as well as tools to aid informed patient decision making. A key assumption underlying quality reporting initiatives of the past decade is that the system will improve when evidence about the comparative performance of providers informs consumer behavior. Although the number of publicly reported measures of quality has grown, research suggests that consumers have little understanding of variations in quality, as well as little incentive to seek out or use such information.57–60 Measures based on adherence to evidence-based standards of care might be difficult to convey to consumers. CONS U M ER EN G A G E M ENT RESEARCH
Research on consumer engagement with evidence (for example, from CER) usually falls into one of three categories: (1) informing consumer choices of providers, (2) using financial incentives to engage consumers in health plan choice or coverage tradeoffs, or (3) engaging patients in clinical decisions at the point of care. Each of these poses different challenges in terms of the decisions to be made, the evidence that might bear on those decisions, and optimal strategies for consumer engagement.
Although advocates argue in favor of simplicity, it can distort differences in performance.61,62
however. In many cases, there is no single preferred clinical option. In such cases, the best choice is the one that most successfully incorporates patients’ values and preferences, but clinicians are not always adept at understanding or eliciting patients’ perspectives.75,76 Yet the risks and benefits associated with different alternatives can be hard for patients to comprehend, even if the medical community understands the statistics well.77 Decision scientists and health services researchers have been working on tools to engage patients in these types of decisions for almost two decades. Studies suggest patients make decisions much more consistent with their own personal values when using these tools and are much less likely to be influenced by the extraneous preferences or hidden biases of the recommending clinician.78,79 This is another technique with great promise for engaging patients in evidence-based clinical decision making, but work is needed to clarify the clinical circumstances best suited to what can be a time- and resource-consuming intervention.80,81
Most patients perceive health care decisions in personal terms, so the emphasis of CER on patientoriented outcomes measures is promising, because it refocuses the discussion about consumer engagement on personal decisions that can result in patient-centered, safe, and timely care.63 Many challenges remain, however. The designs of most clinical studies do not routinely incorporate patient-centered outcomes,64 and patients might not know what value they would assign to outcomes entailing rare side effects or unfamiliar experiences. Finally, research suggests that consumers can be suspicious of discussions of efficiency or effectiveness, fearing these could be a ruse for reducing benefits or access to care.65-67 Scholars have explored methods for engaging consumers and patients; systematic reviews of consumer education strategies reveal some elements of success.68,69 Some new approaches to patient engagement derive from the insight that health care spending is in some sense “the patient’s money.” Economists and policy experts have advocated that patients have more financial responsibility for their clinical decisions, with consumer-directed health plans proposed as a means to this end. Studies have shown that when patients bear a higher portion of cost for individual clinical decisions, they choose less-costly treatments (or no treatment at all). Unfortunately, research has also shown that patients can have difficulty making evidence-based choices and are as likely to defer highly effective and beneficial services as discretionary or unnecessary care.70
Future Research To achieve successful health care reform, CER must do more than simply determine “what works best for whom.” If societal investments are to yield real dividends in more efficient and effective health care, then rigorous research on knowledge translation, provider incentives, delivery system transformation, and patient engagement must provide timely and practical answers for decision makers as well.
Notes For the full list of notes, go to www.mathematicampr.com/chce/brief2_notes.asp.
Value-based insurance design is an approach developed over the past decade to redesign insurance benefits to send economic signals to patients distinguishing highly beneficial services from those that are more discretionary.71–73 For example, copayments might be decreased or eliminated to encourage patients to use a highly effective diabetes medication, whereas copayments might be maintained or even increased for nonbeneficial antihistamines prescribed for viral respiratory illness. Interestingly, initial research on this promising concept has conflicting results, perhaps related to the size and timing of the incentives.74 Clearly, much additional research will be required to clarify the best use of valuebased insurance design, especially in light of consumers’ skepticism of insurance companies’ motives.67
For more information, contact Dominick Esposito at (609) 275-2358,
[email protected]. Mathematica® is a registered trademark of Mathematica Policy Research, Inc. A B O U T THE A U THORS
Dominick Esposito, Ph.D., is a senior researcher and assistant director of Mathematica’s Center on Health Care Effectiveness. Arnold Chen, M.D., M.Sc., is a senior clinician researcher at Mathematica. Margaret Gerteis, Ph.D., is a senior researcher at Mathematica. Timothy Lake, Ph.D., is a senior researcher at Mathematica.
Not all clinical decisions can be addressed by providing financial incentives for patients to do the right thing, Visit our website at www.mathematica-mpr.com
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