Wednesday, August 6, 2008

Physician-Focused HEDIS Is Not Enough

The curmudgeonly Disease Management Care Blog recently provided input on some proposed preventive care measures for HEDIS. While it thinks the proposed methodologies are sound, are helpful and should go forward, it remains unconvinced that physician-based promotion and prevention is really really up to the task. Brief counseling makes a difference, but doctors fall short of consistently providing necessary wellness and prevention counseling in areas such as adolescent tobacco use, alcohol abuse, HIV prevention, osteoporosis treatment, cardiovascular disease in diabetes and obesity. What are the docs trying to tell us?

Surveys have demonstrated that individual physicians prefer to independently review the science that undergirds many wellness and prevention guidelines for themselves and, many times, agree to disagree. They may a) not have enough information, b) conclude the recommendations are in error, c) doubt that they have the necessary skills to carry them out or d) believe carrying them out the will make no difference. For some HEDIS measures, that's not unreasonable. Being human, if they don’t practice what they preach, they’ll also not preach.

The fix is not necessarily ‘payment’ as in performance (P4P). Other surveys have shown physicians can be ambivalent about the role of economic incentives and that many don’t buy into the notion that they should benefit if the patients’ outcomes are improved. Physicians may also doubt that commonly used measures of performance capture what is truly important. This dissonance may be particularly acute when they care for elderly vulnerable patients with multiple co-morbidities. No wonder there’s data showing P4P may have a limited impact.

And then there is the problem of trying to figure out just which physician is responsible for what. As pointed out in this article, patients (in Medicare fee for service, and by extension, in commercial PPO insurance products that don’t require a referral) may be seeing multiple physicians, each with a hand in the management of an aspect of prevention or chronic illness. Many people also rarely see physicians. If HEDIS, which is based on insurance claims and chart audits, can’t identify a responsible physician, is it reasonable to make physicians accountable?

There is also the emerging perspective that patients need to be equal participants in medical decision making. A distinct percentage of health care consumers may therefore decide, based on their goals, values and resources, to not follow through on the prevention recommendations of their physicians. Why should their physicians be held responsible if patients make a decision that is counter to HEDIS recommendations? Shouldn’t physicians be given credit for a) informing their patients of the recommendations (via chart documentation or by use of a special code) and then b) honoring their wishes?

What is the fix for skeptical physician-scientists that are human, resistant to blunt economic incentives, are interacting with a complex web of other physicians and letting patients decide for themselves? The DMCB doubts there is a magic mix of resources, incentives and sticks based on HEDIS measures alone that can be aimed at docs and appreciably change their prevention and wellness care patterns. Rather, it's time to invite other stakeholders to the party.

The DMCB recommendation: it's time to determine and accept the upper range of what is typically possible in physician-based prevention and wellness activities in usual clinical settings. Once that is understood, the sometimes successful use of HEDIS can be integrated with the promotion and measure of wellness and prevention in other sectors of the economy such as school districts, employers, communities, disease management programs, wellness providers and personal health record vendors. In the meantime, promoting physician reliance on the Patient Centered Medical Home's approach to 'outsourcing' prevention and wellness to other local team members may help increase clinic-based HEDIS measures.

Based on what we know about traditional physician approaches to wellness and prevention, is this necessary? Yes. Difficult? Yes. Naive? Yup. Outside the typical mandate of HEDIS? Absolutely. Do consumers deserve new approaches that build on the successful track record of HEDIS? Yes.

When should policy makers start working on this? ASAP.

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