Two ways to prevent treatment overutilization

Given that it is attributed to $158 billion to $226 billion a year in costs to the healthcare system, preventing overutilization is a priority for every payer. Provider organizations participating in value-based care programs also need to curtail overtreatment to earn incentive payments or collect a greater portion of their capitated payment.

While both parties agree on the importance of avoiding overutilization, the devil is in the details. What many provider organizations have discovered is that limiting clinical variation is an excellent strategy to avoid overuse of resources. Although some degree of clinical variation is expected and appropriate, based on the unique needs of patients, excessive costs occur when these variations lead to unwarranted or duplicative tests and treatments. What is also concerning is that a high level of variation has not been shown to improve outcomes, according to a study in the New England Journal of Medicine.

One option is to make more medical evidence available to providers at the point of care to reduce variation. Medical evidence has been positively correlated with improved quality, enhanced patient safety and decreased costs, according to a study in Health Affairs. But with the rapidly growing volume of literature that’s now available electronically, it can be difficult for practicing physicians to stay up-to-date on the most clinically effective treatments. The amount of medical and health-sciences literature published each year increases by more than 9%, and doubles in as few as every eight years.

Having the right tools to ensure the consistent application of effective treatments and expected recovery times is more important than ever. Offering easily interpretable and evidence-based point-of-care decision support tools can help providers take advantage of the most relevant and reliable treatment protocols available, to drive more standardization in care. It just might be the “details” that providers need to effectively reduce overutilization while ensuring high-quality care and rapid successful recoveries.

Bridge the gaps in experience and knowledge

As they have for centuries, physicians rely on their training, experience and intuition when delivering care to patients recovering from an injury or illness. Training, however, can sometimes have gaps, especially concerning recovery expectations. Physicians, outside of a few specialties, are not trained to establish and discuss recovery timelines with patients. Instead, physicians rely on their experience, which may not align with the published evidence and may lead to unnecessary tests or treatments.

When initial diagnostic and treatment regimens prove to be ineffective, or their experience and training is lacking for a certain situation, physicians have few options. Consulting a colleague is one possibility, but that takes additional time that busy physicians do not have at the point of care. Conducting a literature review is another possibility, but it’s also time-consuming and not conducive to efficient workflows. Meanwhile, the patient wants immediate answers.

Physicians may instead opt to experiment with new diagnostic interventions or treatments. In the best cases, the experimentation is effective, allowing the patients to return to health promptly. In other cases though, adhering to evidence-based guidelines would result in more successful clinical outcomes, without overtreatment. Ultimately this leads to improved patient satisfaction, faster recovery times, reduced costs for the payer and increased reimbursement under value-based payment models.

Next: Utilize proven data

Utilize proven data for better outcomes

Physicians clearly need reliable, evidence-based point-of-care tools that can quickly deliver clinical guidelines that take into account unique patient factors. Equally important is a physician’s access to illness and injury duration tables that are informed by population data and refined by expert medical consensus. With objective duration information in hand, physicians can set realistic expectations for patient recoveries and avoid common missteps, such as unnecessary activity restrictions and wasting time and resources on treatments unlikely to contribute to recovery.

When these decision-support tools are integrated with the electronic health record, physicians can access recent tests and procedures that help encourage standardization, reduce unnecessary duplication and facilitate better coordination. Likewise, each provider in that patient’s care team who has access to the evidence-based tools can also pursue a consistent, proven treatment plan.

At the point of care, where it is most needed, physicians can review physiological duration estimates and guidelines to help patients return to work or normal activities safely and efficiently. To improve performance, physicians can leverage a robust analytic framework to benchmark clinical outcomes against real-world case data at the diagnostic group or code level for even more insight into utilization and variation.

Following established clinical guidelines and utilizing recovery duration tables and analytics enables physicians to more efficiently pursue a proven care path that helps individuals return to full health and activity faster without receiving care that is unlikely to improve their outcomes. Combined, evidence-based decision support and actionable clinical intelligence at the point of care is a win for the physician, the payer and the patient.

Joe Guerriero is senior vice president of MDGuidelines at ReedGroup.