Monday, September 26, 2011
Designing A Smarter Congressional Staffer
That's what the Disease Management Care Blog often hears when it's on The Hill talking health policy, resolutions and legislation with Congressional staffers. After several visits to Congress, the DMCB discovered that this abiding interest in altering physician behavior underlies much of the current background work on provider reimbursement, liability reform, "innovative" ACOs, value-based purchasing and budget cutting.
Consider the case of staffer Kristin Smith (not her real name). She is a recently graduated lawyer who, along with her elected boss, is alarmed by how health care costs are threatening to bankrupt the U.S.. Multiple letters from the district have warned against "cutting Medicare," while the doctors want the SGR "repealed" and the hospitals are the number one employer in the district. Cutting payment rates or changing eligibility are politically unpalatable. Given the results of the Dartmouth Atlas, wouldn't it much nicer if there were a way to get docs to order fewer tests and use less expensive technology less often?
What Kristin and her colleagues often don't realize is that changing physician behavior is notoriously difficult. Considerable research spanning several decades has shown 1) no single intervention works all that well; it takes multiple tailored, overlapping and mutually supportive interventions, 2) once the interventions stop, physician behavior rapidly decays back toward the baseline, and 3) dedication to patients plus professional independence combined with local practice patterns and culture are a huge influence in day-to-day clinical medicine.
In other words, doctors live by more than bread, guidelines, bonuses and payments alone.
In the opinion of the DMCB, the good news is that smaller regional organizations, such as local health plans, physician and hospital groups understand what they're up against and have amassed a track record of economic incentives, educational programs, peer support and non-physician disease management programs that make a difference. They're close to their providers and know how and when to apply that secret sauce to change physician practice.
Which is the irony for Kristin. Despite the considerable financial resources and power of a vast Federal government, her predecessors' good ideas like "meaningful use" "pay for performance" and "value-based purchasing" are not meaningfully transforming the practice of medicine. In fact, other supposed game changing interventions like the SGR and the RBRVS have only made things worse.
That being said, the DMCB reports some good news: Kristin and her colleagues are listening and learning. Many are coming to understand the limited ability of Washington's blunt-force policy and payment mechanisms to reach across culture, education and professionalism to gently tilt the doctor-patient relationship in the right direction.
Want to design a smarter staffer who knows how to change practice patterns? It takes knowing how similar efforts have worked in the past, understanding what the science says and appreciating how local markets can be harnessed.
Next step: designing a better member of Congress.