Grand Rounds Blog

The release of the Centers for Medicare and Medicaid Services data got people’s attention because everyone loves to know the hidden prices of things that were previously shrouded in secrecy. The CMS data revealed the sticker cost of various medical procedures, and how they differ from doctor to doctor: a colonoscopy that cost $4,000 in one doctor’s office costs $3,200 in another.

That’s useful information—to a point. But to some extent, it’s also the wrong conversation. By pulling back the veil on cost, the release of the CMS data has created another distraction that prevents us from talking about quality. For example—should some patients even have colonoscopies in the first place? And how will they know whether they should get one? Which physicians are prescribing procedures that patients don’t need, and how will patients be able to tell the difference?

These are life and death questions that aren’t answered by the CMS data. And with millions of dollars in annual wasted healthcare spend piling up every year, there’s too many traps out there—too many ways for patients to spend money needlessly or even put their lives at risk.

Here are a few examples where lack of quality transparency causes patients to stumble into dangerous terrain.

Location matters. The sad reality is, rural areas often have great, competent doctors who are nevertheless not well-versed in highly specialized procedures. New research shows that patients who undergo a partial nephrectomy, or the removal of half of a kidney, have a 19% lower mortality rate than patients who are prescribed the much more common full nephrectomy, in which they lose the entire kidney.

But physicians in rural areas only perform this delicate procedure 44% of the time, whereas doctors in more populated areas perform partial nephrectomies 81% of the time, That means that the majority of rural patients are undergoing an outdated procedure and having their entire kidneys removed. That’s dangerous. It’s potentially even fatal.

Metro areas aren’t safe either. Doctors in high-income neighborhoods are more likely to prescribe G-CSF, a drug used to treat cancer patients prone to infection. But it’s a drug that’s only effective and necessary in 2% of cases. From what the data suggests, this is because of the intervention of Amgen sales reps, who will network with doctors and encourage them to prescribe G-CSF above the recommended guideline.

And yet, data has shown that only 1 in 10 patients actually end up deriving clinical benefit from the drug. Unsurprisingly, the national association of oncologists has deemed the overuse of G-CSF a huge problem.

Invasive/costly versus non-invasive procedures. There’s countless examples of an overuse of invasive, costly procedures when less costly ones will suffice. Grand Rounds sees this frequently in terms of the initial diagnosis/treatments that our patients bring to us. For example, we see rotator cuff surgeries used when a much less-invasive arthoscopic surgery would be better. We also see far too many needless cardiac stents following routine angioplasties, and we see far too many unnecessary spinal fusion procedures.

We overturn these poorly prescribed procedures and treatments as we see them, but ultimately we’re only seeing a small fraction of the cases that run through the healthcare system every year. That means there’s a lot of waste and spend out there.

Employers are on the Hook. The problem isn’t simply the impact on individual people and their lives, although of course that matters tremendously. The problem is that the lack of understanding of quality inside the healthcare system creates a systemic problem at the employer level, which adds up to billions in costs.

Companies create and design benefits networks with medical providers as best they can, trying to balance quality and cost. But once those networks are up and running, there’s very little they can do to guide their employees to the top medical specialists within a network. And when large-scale medical problems erupt, employers end up being on the hook for millions of dollars.

The result might be a kind of post-traumatic stress disorder, such as when the CEO of AOL recently vented about “distressed babies” costing his company millions of dollars at an all hands meeting—an incident that went viral in the press.

And it’s a problem that feeds on itself. When people get poorly prescribed treatments or procedures, they often have to back and get another one. And another one. And another one. Employers find themselves having to ratchet up premiums and tighten networks—which, again, forces employees to see more of the wrong kinds of doctors.

It starts to become evident why cost, although important, is really the wrong way to frame the problems with healthcare. What’s more important is quality. Which doctors represent quality medical outcomes? And equally as important, how can patients tell the difference at a time when they desperately need to know?

A Prescription for Quality

So how should the debate be framed in order to tackle the quality issue? My own prescription consists of a few steps:

Let’s talk about a way to find the good doctors. There’s no such thing as a doctor rating system—not really. U.S. News and World Report articles don’t count. How should doctors be rated? What criteria should be used? And how can the results of those ratings be as public as the listing of doctors in an insurance provider directory?

Let’s talk about a way to get patients to those doctors. The way to ensure quality outcomes is to provide a path that allows patients to see the physicians who can help them. Geography, insurance networks, and even physician availability shouldn’t be a deterrent. Technology can help. So can the use of “asynchronous” medicine. Access matters, and it needs to be front and center in the national dialogue.

Let’s not stop until we cover every specialty. I’m not suggesting we simply talk about the top doctors in Atlantic City. I’m suggesting we figure out where the top renal oncologists are, in every metro and rural area. And then we do the same for cardiology, gastroenterology, orthopedics, rheumatology, and every other major medical category.

You can see from all of this that there’s an awful lot for us to talk about in regards to physician quality. And to be honest? Those conversations need to happen well before anyone worries too much about the cost of an MRI.

Other things you might be interested in.
5 Ways to Improve Healthcare Utilization
Our North Star: Matching Members with High-Quality Doctors
Member Impact Stories: $6.6M Back to Members and Counting