Following the Evidence

Weighing the Evidence

Local health care providers are not only utilizing the clinical guidelines; they are also being rated on the results of their treatment. To be effective, evidence-based medicine relies on public reporting of processes and quality, and Minnesota is a leader in such reporting, Isham says.

The Minnesota Department of Health released its second set of hospital ratings in January. The department’s report looks at whether a hospital:

• Requires staff to use computers to order medications, tests, and procedures;

• Has experience and good results in performing some high-risk procedures (i.e., coronary artery bypass graft and abdominal aortic aneurysm repair);

• Has an intensive care unit staffed by personnel with training in critical care; and

• Has put in place 27 procedures to reduce medical mistakes.

The hospital rankings can be found at the Minnesota Health Information site.

Clinic facilities received their “report card” last November from Minnesota Community Measurements, a St. Paul nonprofit set up by the Minnesota Medical Association and seven health plans. The report card measured how often clinics did disease screenings and immunizations, and how many patients in certain categories reached treatment goals. The yardstick for each measurement was the treatment indicated by research to be the most effective. The report cards rated performance in the areas of children’s and women’s health, diabetes, high blood pressure, asthma, and depression.

The measurements mostly measure processes, Fazio says. For diabetes care, caregivers are measured on how often they perform a particular blood test and on the percentage of patients who score 7 or lower on the hemoglobin A1c test (a positive result) and the percentage who score 9 or higher (indicating a level that can lead to problems). “The percentages on this test don’t measure a health    outcome as such, but they’re a proxy for an outcome,” Fazio notes. “Hospital ratings measure more outcomes because you can quantify things like surgery infections or fatality rates.”

The Bottom Line

Some health care professionals say the next step in solidifying quality improvement is “pay for performance” bonuses, where insurers pay providers for meeting goals in patient care. The goal is to lower costs in the long run when correct care is given the first time, limiting waste and unnecessary treatments.

“We mostly pay for piecework in medicine today, whether it’s good or bad,” Mosser says. “We sometimes pay more to fix problems from poor care because more procedures are done. Changing the emphasis to paying for good results would have an enormous impact on improving health care.”

“The incentive now is to see the extra patient or give out unnecessary antibiotics to keep visits shorter,” Bershow says. “The system would work better if doctors could take the time to talk patients out of antibiotics or procedures they don’t need.”

Mosser thinks that if 15 percent to 20 percent of what insurers pay to providers was based on performance, it would make a huge impact on quality. HealthPartners, the state leader in bonus payments, pays contracted providers, including its own clinics, about 5 percent of its total payout in pay-for-performance bonuses; it pays hospitals about 2 percent. In 2005, most of HealthPartners’ $11.5 million in pay-for-performance money went to clinics that met improvement goals specified in contracts.

Carolyn Pare, CEO of Bloomington-based Buyers Health Care Action Group, a coalition of large local employers, says that evidence-based medicine can improve care by making it more consistent and eliminating less effective and unnecessary care. Pare’s group is launching a pay-for-performance initiative in Minnesota. “Our members get the relationship between care variation and costs, but many employers don’t know what they’re paying for,” Pare says. “They need to ask ‘What am I buying?’ and ‘What are the various plans doing to get the best value for my costs?’ Because who cares if you have a plan with the cheapest MRI if you end up paying for five because someone didn’t get it right?”