Arming doctors with evidence to achieve clinical and financial goals

July 11, 2018

By empowering physicians with evidence-based guidelines, they are better-equipped to make clinical decisions that are cost-effective and drive high-quality outcomes.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions expressed here are that of the authors and not UBM / Medical Economics.

Physicians have never had a greater need for evidence-based information to evaluate the effectiveness and risks of alternative therapies and treatments. New reimbursement models include financial rewards for the delivery of quality, cost-effective care, which means doctors require tools that explicitly identify the value and risks of particular interventions, based on scientific research and evidence.

With ready access to current information, physicians can maximize their earning potential and diminish the risk of financial penalties, while simultaneously advancing the Triple Aim of improved population health, lower health costs, and a better patient experience.

If you are a physician, you’re aware of how challenging it can be to achieve Triple Aim goals and value-based care objectives. You often must a navigate a mix of old and new payment models; you must choose between the latest clinical protocols and possibly unaligned historical “best” practices; and, you must interpret population-level care guidelines and evaluate their applicability to an individual patient’s values and preferences.

Fortunately, thanks to a mix of new policies and regulations and advanced technologies that make evidence-based content more readily available, physicians are increasingly better-armed to achieve their care and quality goals.

Aligning evidence-based medicine and financial incentives

Most physicians still rely of traditional fee-for-service models for the bulk of their compensation. Newer fee-for-service plans, however, often include quality components that incent clinicians to follow evidence-based guidelines.

For example, established care guidelines recommend that patients with diabetes, hypertension and other chronic diseases regularly visit their doctor for preventative care and ongoing treatment. Often these guidelines align with physicians’ financial incentives so that clinicians encourage regular follow-up care to drive better outcomes.

Physicians that are subject to Medicare’s Merit-Based Incentive Payment System (MIPS) are also motivated to adhere to evidence-based medicine standards. Reimbursements and penalties under MIPS are tied to quality performance, so providers are driven to deliver optimal outcomes and cost-effective treatment.

Accountable care organizations (ACOs) also tie reimbursement to quality activities. Physicians have the potential to raise their quality scores and qualify for bonuses by adhering to evidence-based medicine protocols, especially under track 1 of the Medicare Shared Savings Program (MSSP). Physicians also have the potential to earn shared savings if the ACO reduces Medicare costs by more than a minimum amount-yet another reason for clinicians to seek evidence-based, cost-effective interventions.

By adhering to evidence-based medicine guidelines, physicians can earn higher rewards while participating in risk-based payment models, such as an ACO enrolled in track 2 or track 3 of the MSSP, or a Medicare Advantage plan administered by a private insurer. As reimbursement models continue to add value-based metrics, physicians will demand ready access to evidence-based protocols to guide preventive care efforts, better manage patients with chronic conditions, and minimizing unnecessary interventions.

Challenges to adopting evidence-based medicine

Despite aligned financial incentives and well-intentioned clinical practice guidelines, physicians are sometimes slow to utilize evidence-based medicine in clinical practice. This is especially true when new evidence challenges conventional wisdom.

Consider, for example, a well-publicized study that examined invasive therapy for stable coronary artery disease. In 2007, strong evidence emerged that found a three-drug therapy for chronic stable angina could be as effective as invasive placement of a coronary stent. However, a decade later, cardiologists acknowledge that the (less-expensive) three-drug therapy remains underutilized, while stents were overutilized. Indeed, as recently as 2016 the American College of Cardiology reported that close to 50 percent of stents for non-acute patients were placed without appropriate indications.

Despite strong evidence, physicians often take years to change practice habits. Evidence adoption is further delayed when doctors cannot easily translate population-based guidelines to the unique needs or preferences of an individual patient. Making the best and most meaningful evidence guidance applicable to a specific patient is hardly straightforward, as suggested in a recent systematic review of 48 studies and over 13,000 clinicians. According to the authors, clinicians overestimate the benefit of a test or treatment 32 percent of the time and underestimate the risk of harm 34 percent of the time.

Leveraging curated evidence to achieve clinical and financial goals

The incorporation of evidence-based medicine into everyday practice remains a challenge, but physicians now have increased access to more tools to help them evaluate the relative value of different interventions.

Consider the Choosing Wisely campaign, which the American Board of Internal Medicine launched in 2012. ABIM publishes a list that includes specialty society warnings about several hundred tests or treatments that should be avoided under specific circumstances. Physicians able to stay abreast of pertinent details related to their specialty are more likely to select interventions that improve care and optimize resources.

Other sources of evidence-based guidelines include the Cochrane Collaboration, specialty society “journal clubs,” and commercial providers of order sets and care plans. Such organizations perform systematic evaluations of new studies to assess their importance for patient outcomes. In addition, Right Care Alliance, the NNT, and similar coalitions work to identify and reduce overutilized healthcare interventions by clarifying the risks and benefits of various tests and treatments.

By arming physicians with evidence-based guidelines, they are better-equipped to make clinical decisions that are cost-effective and drive high-quality outcomes. In order to achieve Triple Aim goals and value-based care objectives, healthcare organizations must leverage available technologies and resources and give their physicians ready-access to the most current evidence-based data.

Ross Ellis, MD is an ABIM-board certified internist and medical director at Zynx Health to help implement evidence-based care guidance across a broad range of health systems in the U.S., Canada, and the Middle East. In his own practice in eastern Pennsylvania he has helped manage clinical decision support for EHR-based workflows. Ellis completed an MD degree, MPH degree, and residency training at Columbia University.