SCGhealth Blog


Payer plays the pivotal role in successful decision support initiatives for physicians

Monday, January 26, 2015

By: Scott Kraft, CPC, CPMA

A recent report from the RAND Corporation of the effectiveness of clinical decision support programs designed for physician use details that a recent ‘Medicare Imaging Demonstration’ (MID) project ordered by Congress shows that decision support may not actually work to reduce costs and-or change physician ordering patterns.

If this survey represents the sum of our efforts to help guide physicians toward better utilization of advanced imaging and drug therapies, the health care industry will turn a blind eye towards more effective methods to significantly reduce unnecessary healthcare spending and help physicians and health plans operate more efficiently, believes Steve Sandy, co-founder of Boston-based Informatics in Context (IIC).

To start to understand why, consider how the demonstration was structured. Physicians basically decided which test they wanted to order, then consulted a decision support tool that validated, or questioned that decision.

In many cases, the decision support tool could not link the most appropriate (or inappropriate) physician ordering decision to a specific clinical policy. More than two-thirds of the orders could not be linked to a specific clinical care guideline. Also, the process of using the decision support system took an average of an additional three minutes, which disrupted the physician’s existing workflow.

In other words, a likely result of the clinical decision support system was that the physician would make a medical decision to order a certain test based on judgment and years of experience, then spend additional time going through a validation process that, more often than not, couldn’t offer any validation or guidance tied to a specific policy.

Two additional problems were that the demonstration covered a relatively small number of imaging services and a significant number of ordering decisions fell into an “uncertain” category because the guidelines for a clinical scenario were not definitive.

It’s no small wonder that when the demonstration showed, in the face of spending extra time to yield an uncertain result, that physicians became frustrated with the whole idea of clinical decision support, and that they tended to stick to their own judgment when it came to ordering advanced imaging tests.

The consequence of the design of the study is that ordering patterns for tests that were part of the study did not change and there was no cost reduction.

Before we let that be the end of it, let’s circle back to the reality of why these studies are being requested in the first place. Utilization trends and research show that physicians are over-utilizing diagnostic tests and that there is no clear consistency between the patient’s condition and the test ordered.

Because prior authorization is currently a labor intensive manual activity for both the provider submitting prior authorization requests and the insurance payer, the number of procedures for which it is required is much lower than it needs to be to ensure efficient utilization of medical services. Payers and providers are also prone to making mistakes which result in unnecessary testing, over-utilization, and misuse.

Tests that are not medically necessary end up getting approved, and in many more instances, the most expensive test gets approved when lower cost tests are just as efficacious. Patients and providers alike wait longer than necessary while the insurance approval process plays out.

Then there’s human nature. Without oversight, physicians driven by liability fears or ownership stakes in medical equipment are typically more likely to default in favor of more testing than less, and ordering more expensive tests – based on the current fee-for-service reimbursement model. Ownership stakes often create a conflict of interest in the testing equipment, as Sandy points out.

Ultimately, the flaw in the clinical decision support demonstration on the physician side was that, more often than not, the final decision over what test to order was still the exclusive domain of the physician, with no motivation to order the appropriate lowest cost test, Sandy notes. In fact, ordering the most appropriate, lowest cost test would only cost the provider money.

Given that the physician trusted his judgment in the first place, the system often had no clinical evidence to counter it, nor was there any downside reimbursement consequence for choosing the more expensive test. As a result the physician had no motivation to change his judgment, certainly not to order less expensive tests.

Payers have and must exert control
The second reality of clinical decision support on the physician side is that it has existed for years, in the form of coverage determinations and appropriate use guidelines and policies developed and published by payers of health services.

However, enforcement of appropriate clinical care guidelines that are the most cost effective is another matter entirely. In a system that is based on manual processing of requests for pre-authorization, it comes as no surprise that physicians routinely order the most expensive tests even though lower cost appropriate tests could be utilized. Over-utilization and unnecessary testing are widespread industry issues.

The flaw of the RAND study’s decision to continue to cede full decision making to the provider is that it may lead payers to conclude that they can’t do better than the current system. Such a conclusion will lead to tens of millions of dollars in appropriate and unnecessary spending on diagnostic tests in the coming years, Sandy believes.

A much more effective, clinically appropriate, and cost saving alternative is an electronic and automated clinical decision support mechanism that essentially allows the payer to automate its prior approval processes in real-time for all medicine, including tests, advanced imaging, outpatient procedures, inpatient admits, stay extensions, labs, durable medical equipment, and expensive drugs covered under medical benefits.

Prior authorization approval would then be based on the payer’s policy guidelines and appropriate use criteria – which takes the physician’s own payment incentives out of the decision process, Sandy suggests.

If clinical decision support and the resulting payment approval process was enforced from the payer side, then the right care would be delivered at the right time for the right reason based on evidence-based guidelines. An automated approval process enforced from the payer side would actually enable clinical decision support to work, and significantly decrease costs by maximizing automation based on appropriate use criteria, he adds.

Under this system, a physician seeking clinical decision support based on a patient’s condition isn’t given vague guidance, or told that there is not quite the right clinical match to either validate or repudiate the ordering decision that the physician has made.

Instead the physician is directed, based on the payer’s policies, to start with a certain diagnostic test that evidence-based research shows is a cost-effective way to start treatment for a certain condition, Sandy says. In the small percentage of cases where that first test may not prove to be definitive, then the payer’s clinical support tool would escalate the provider to another test that could provide more definitive guidance.

Huge cost savings will come from automating the approval process, requiring physicians to order the most clinically appropriate and efficacious first test at the lowest cost as a method of guaranteeing payment from a payer.

Appropriate Use Criteria (AUC) are the only truly effective means to ensure proper and appropriate use of medical procedures that drives medical decisions towards patient centric, evidence-based medicine. When paired with prior authorization, AUCs promote the effective treatment regimens, advancement of patient care, while containing costs.

Congress is poised to make some very big decisions about the future of US health care policy and current payment methodologies. One thing that both parties will definitely be seeking to achieve as the legislation is debated is identify ways to dramatically reduce overall health care spending while improving patient outcomes.

The push for increased automation and efficiency of the clinical decision support process – outside of the hands of the physicians themselves – will result in substantial cost savings and real operational efficiency, enabling better patient care and improved outcomes for more patients, for more conditions at much lower cost, Sandy believes. It will produce an outcome that Congress and policymakers expected when the original clinical decision support demonstration was authorized – real cost reduction without sacrificing quality or care.



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