CUTTING WASTE (AND MY OWN THROAT)

Last time I posted the idea of identifying physicians and providers who are utilization outliers when it comes to resources. Physicians are sensitive about being targeted regarding their practice patterns, and rightly so. In the current culture, doing what is perceived as too little places your head on the legal chopping block. Doing too much—well, there isn’t a great deal of downside to doing too much, and it can be lucrative. Besides, the patients like it and often demand it, particularly with a third-party payer holding the purse. Being identified as an overutilizer is another story. This carries the pernicious implication that you’re either greedy or incompetent, and may expose you to investigation for fraud. 

Now, identifying “overutilizers” is fraught with hazard. First, as any physician will tell you, the patient population the individual physician treats can vary substantially, even within specialties. A tertiary care specialist who is internationally renowned may have a disproportionate number of the most severe and complex cases, requiring more extensive workups, relative to a local internist in an educated, affluent community with good access to preventive care. Then there is the question of medical judgment. Guidelines help but cannot take the place of this in a field that is still a complex stew of science and “art.” Do we want to hamstring our doctors by penalizing them for ordering another test when their threshold of discomfort is crossed? And the threshold does vary from practitioner to practitioner based on disposition, training and experience. One size does not fit all if you want to have enough physicians to service the medical community. 

Finally, spotlighting doctors who fall outside the usual range runs the risk of turning many well-meaning, conscientious physicians into miscreants, when only a small proportion truly warrant the designation. 

So I propose that the individuals be identified and notified for their personal edification through professional boards, not government agencies. There should be no penalties or action whatsoever. I believe this will have a two-fold effect. First, it will educate. I think a lot of physicians out there have no idea where they stand as far as utilization within the local and national community. Second, it will motivate. A personal reassessment of practice patterns and re-education is likely to follow, driven by a desire to improve. The more defensive among us (and the true miscreants) are like to be more motivated by fear of reprisals, but again, the data presented should not be actionable for the reasons mentioned. I believe the system can be largely self-correcting over time. 

So, maybe I’m stupid, naïve, felonious or idealistic, depending on your viewpoint. And I’m not unaware of the danger of data cyber-theft. This is one of the biggest risks and will have to be very carefully policed. By separating the data from the provider identifiers I believe a system could be devised that protects their anonymity. The bottom line remains that our health care problem is of a magnitude that isolated, poorly targeted solutions that ignore the practice patterns of the physician can never work. Tort reform may get us half way there, but I don’t that alone will carry us to the finish line. What do you think?

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