What Atul Gawande can learn from the nation’s leading employers
As the new CEO for the BHA healthcare consortium, Atul Gawande, MD has just begun his national listening tour with employers and employees alike. In his new role, he is expected not only to encourage and shape new ways of thinking about healthcare delivery, payment and access, he's expected to shift the lens onto the role of the consumer and the importance of the patient-physician relationship. One of Dr. Gawande’s key strategies to reduce healthcare costs is to reduce waste in the system — not on the supply side, but on the demand side. If he listens carefully to some of our nation’s leading employers, he’ll learn some have already figured out a way to do just that.
Eliminate unnecessary care
Today, nearly 15% of patients experience an incorrect medical diagnosis that subsequently leads to unnecessary care. A recent Mayo Clinic study found that among patients who come to the clinic for a second opinion, an astounding 88% leave with a new or refined diagnosis. Even when they get an accurate diagnosis, patients often experience ineffective and inefficient treatment regimens. This represents an incredible opportunity to eliminate waste in our healthcare system.
Several large employers have already realized that getting the diagnosis and treatment correct the first time is key to saving money, but more importantly, vital to getting their employees healthy and back to work. Our internal data shows that the majority of patients who seek an expert second opinion have a change in their initial diagnosis 25% of the time and a change in their treatment plan 65% of the time. This suggests their initial provider did not provide top quality care, with the potential for wrong tests and treatment. For this reason, more employers are now offering second opinion services as an additional employee benefit. Second opinion services are becoming mainstream: NBGH statistics show that 66% of employers now offer them, an increase of 47% over last year.
Help employees find top quality providers
Workers need more than just access to a second doctor with another opinion. High quality, patient-centered care starts with having a high-quality physician, as physicians have significant influence over treatment options and clinical outcomes. Unfortunately, when left to their own devices, employees don't have the tools and support to find high-quality providers. Transparency on physician performance data is sorely lacking, and while employers promote their health plan websites and premium designation provider listings, patients can’t comprehend what this data means.
This means patients often turn to Google, where they will stumble upon “doctor review” sites such as Yelp with ratings associated with the patient experience with that physician (i.e., personality, office wait times) versus meaningful health outcomes measures such as readmission rates, surgery infection rates, and health outcomes. Consumers also tend to believe that quality is related to the location of the physician’s practice and the prestige of the medical institution. Our research shows that googling leads them down the wrong path as the top doctors on Yelp are not actually high-quality physicians.
For this reason, best-in-class employers aren’t just offering second opinion services. Leading employers and benefits managers in the public sector are offering employees more help identifying and choosing the best physicians and hospitals.
Foster shared decision making
We can help employees get a second opinion and find an excellent doctor, but it is also critical to educate the patient about their diagnosis, condition, and care options so they can choose the treatment that is right for their needs and consistent with their values. This is a crucial piece of the puzzle because studies show that greater patient activation is related to better health outcomes.
For many conditions, multiple treatment options exist (including the possibility of doing nothing, when appropriate) and for some "high variation, high-cost conditions," such as back pain and hip or knee osteoarthritis, surgery is an option but so are minimally invasive procedures, medications or physical therapy. Different options entail different risks, side effects, and benefits; incorporating patients' preferences and values is critical.
The foundation for informed medical decision making is helping patients understand their evidence-based, relevant options unique to their individual preferences. As it turns out, when patients follow their needs, values, and preferences, there are often cost savings too.
Numerous studies show talking to consumers about their condition and the pros and cons of various treatment options can have a positive impact both on healthcare spending and on long-term health outcomes. For example, in 2008, the Lewin Group estimated that implementing shared decision making for just 11 procedures would yield more than $9 billion in savings over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs — with up to 38% fewer surgeries and savings of 12 to 21% over six months.
After going through a shared decision-making process, typically 40% of the employees we help guide either reduce the invasiveness of the pre-intended surgery or avoid unnecessary surgery altogether. This is good, high-quality, efficient healthcare.
One of our customers, a large manufacturing company, documented that they saved $5.6 million with only 251 employees by having them participate in the company's Surgery Decision Support initiative for five surgical conditions that tend to have a considerable variation in cost and quality.
In an era of healthcare disruption, we expect to hear more from Gawande about fixes in the supply side of the system and on the demand side, as he and other leaders advocate for deep patient-doctor collaboration around shared medical decision-making. Benefit leaders, in partnership with their health plans and consultants, can have success improving the quality of care, avoiding unnecessary, wasteful care and improving health outcomes by helping employees with decisions involving both the quality and appropriate use of healthcare.