Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Practices Must Change for Cost Effectiveness Research to Work

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It is unclear in the U.S. if Cost Effectiveness Research (CER) studies are compelling enough to overturn insurer's coverage decisions or reduce well-established procedures--Beware the status quo

"if a procedure has spread widely, large, well-designed studies must show that it’s clearly ineffective or harmful before payers and providers will abandon it; for a new procedure, the assumption is that effectiveness has not been established, so good studies demonstrating effectiveness are required for its adoption. Increasingly, funding agencies and policymakers aim to subject established practices to greater scrutiny, since often interventions adopted without strong evidence are later found to be ineffective or not as effective as initially thought.

ACA features such as bundled payments, shared savings programs, and outcomes-based payments offer mechanisms for stimulating the adoption of practices that are supported by CER and the abandonment of practices that CER calls into question. The benefits for patients are large, as are the potential savings. Support for CER, reinforced by appropriate payment changes, is likely to represent a very good investment for the federal government and U.S. taxpayers."

Adam G. Elshaug, M.P.H., Ph.D., and Alan M. Garber, M.D., Ph.D. "How CER Could Pay for Itself — Insights from Vertebral Fracture Treatments."   NEJM, April 13, 2011 | 

Speaking of practices changing, 3M clients who manage accountable care organizations note the organizational benefits to participating in such quality improvement / utilization management efforts, especially when there is shared savings to be had, as follows:

  • "Increased focus on efficiency and appropriate site of service
  • Greater participation of primary care physicians for preventive care
  • Greater investment in patient-centered care and patient engagement
  • Expansion of care coordination from hospital-based discharge planning and transitions of care to include post-acute and community-based services"

Kristine Daynes (3M Health Information Systems). "One more year and five lessons learned from the MSSP ACOs." Posted Inside Angle blog. September 9th, 2016 

What does the future hold for the Shared Savings Program?  It depends on our intelligent use of data