Eliminating Waste, Promoting Value Across the Health System

Wasteful Care

At the beginning of his address, Cohen showed a scatterplot of the cost of care compared to the mortality rates for three common diseases: colon cancer, hip fracture, and acute myocardial infarction. There was no association seen between the cost of care and the quality of care provided.

“A very, very few number of providers are actually practicing at the optimal intersection of both quality and efficiency,” Cohen articulated. “They maximize the quality of their care; at the same time, they’re maximizing their efficiency of care.”

To emphasize his point, Cohen gave an example of the South Korean thyroid cancer screening experiment. In 1999, South Korea made a national goal to screen its entire population for thyroid cancer even though mortality rates were close to zero in the country.

“Ten years later, the incidence of total thyroidectomy and radiation therapy for thyroid cancer went up 13-fold, but the mortality didn’t change. It’s hard to get better than zero,” Cohen pointed out.

Cohen said this example demonstrates unnecessary and potentially harmful care that was delivered to an entire country. He noted that the United States is seeing a rise in thyroid screenings as well, so the problem is not unique to South Korea. 

Wasteful care can be categorized in one of two ways. The country-wide thyroid cancer screening is an example of low-cost treatments done so frequently that they accumulate a hefty price tag. Cohen proposed that other examples of this kind of wasteful care included colonoscopies for patients over 75, pulmonary CTA for low-risk pulmonary embolism, and knee arthroscopy. He argued that each of these treatment options was low cost but wasteful given their frequency and lack of evidence to support their effectiveness.

The second type of wasteful care Cohen outlined was expensive treatment or procedures done less frequently. Examples of these included Gleason Score for prostate cancer and lumbar fusion for osteoarthritis. Cohen noted neither of these treatments showed any empirical evidence of their effectiveness and were particularly costly.

Knowledge Gap

Some of this wasteful care is the result of a gap in knowledge. It can take anywhere from 5 to 17 years to integrate evidence-based practices published in the literature to become fully integrated into clinical practice. Cohen proposed three reasons why this is the case.

"Frist," he said, "there are 100,000 pages of new medical science published monthly, and nobody can keep up with that."

Such a large volume of literature is impossible for a single physician to stay up to date.

Secondly, providers are busy. Many of them are overworked and do not have time to stay on top of the new literature, even if it were a manageable amount.

The third and most important reason for Cohen is a sociological phenomenon based on self-validation.

“When you present information that conforms with a revenue stream, it’s very rapidly adopted,” he explained. “But when you present providers information that conflicts with their revenue stream, they tend to find methodological flaws with the study and dismiss results.”

All three of these reasons create a challenge to integrate new practices into clinical standards and limit the ability for healthcare systems to avoid waste. If waste is identified in the medical literature and procedures are seen to be ineffective and non-efficient. Still, providers are slow to change their practice, and the system of waste is continuously perpetuated.

Simple Solutions

Simplicity in a complicated system is vital. Therefore, the OptumCare model aims to work through simple steps to optimize care.

The first step, Cohen noted, was getting providers on the same page and understanding that they are responsible for delivering both wasteful and harmful care. They need to have a willingness to change.

“That’s the ground rule for embarking on a program like this,” he said.

Next, providers need education around their quality of care and cost of care metrics. Many providers are unaware of this.

"This is education around incremental cost-effectiveness ratios, quality-adjusted life years, pharmaco-economics," Cohen explained. "This is the information of the economics of medicine and how it interacts with clinical medicine in such a way that you're delivering the right care."

In the exam room, providers can then leverage decision aids that consider costs at the point of care.   

Providers also can see quality and cost metrics for referring specialists, so once a care decision is made, they can refer their patients to the most efficient and effective specialists. 

“Primary care physicians are very, very quickly learning to direct the referrals to the most cost-effective providers. Sharing that data, unblinded, is an incredibly powerful solution,” Cohen furthered. “At the end of the day, what you wind up with is a high performing provider network.”

Clinicians previous never had this information readily available to them, so their referral patterns were driven by their relationships with their colleagues rather than hard data on who delivers optimal care.

“Primary care providers rarely have this information at their fingertips,” Cohen noted.

So, having this information available allows for a more informed decision that ultimately drives down costs.

Empowering Providers

Giving clinicians information on quality and cost empowers also allows them to self-examine their own cost and utilization metrics compared to their peers.

Previously, medical directors or chief medical officers were the ones to look at this data. OptumCare provides every primary care clinician with this information.

“It shows their performance against quality and cost measures. It shows arrows up and down as to how they’re improving or not improving over time,” described Cohen. “All of our providers share this information unblinded. We all get a look at each other’s reports.”

Part of the comparison is so providers can understand why their costs of care might be higher than their peers or why their utilization rates are higher. It allows for self-reflection and adjustment of practice if needed.

"If you shine a bright light on how people are performing, particularly in an unblinded way, it helps direct how patients or health providers will manage their care," Cohen furthered.

The goal of giving providers this information is to empower then to drive their patients to with quality, low-cost specialists and ultimately eliminate waste.

“At the end of the day, what you’re looking for is a high-value group of providers that have taken a good portion of the wasted care and really run it out of the system. This can be done specialty by specialty,” continued Cohen. 

Shared Decision Making

Many of OptumCare solutions give providers algorithms to leverage as decision aids, but there are some areas of care that do not lend themselves to algorithms. One example Cohen provided was lumbar fusion for spinal care.

To help providers and patients make informed decisions, OptumCare has a model that shows the statistical likelihood of a patient benefiting from a lumbar fusion based on aspects of the patient’s medical history and demographics.

The decision-making tool might show for a particular patient that there is a 57% chance of a benefit. To a patient in serious pain, a 57-percent chance of improvement might be worth an operation, but to others with more mild pain, a 57-percent chance of improvement may not be enough to drive them to lumbar fusion.

What the tool does is allows providers and patients to share in the decision-making process based on the individual patient data rather than the provider’s success rates.

Cohen explained that patients typically hear from providers about their personal success rates, saying that 85% of their patients showed improvement after the procedure

“This is not a targeted likelihood of improvement based on a specific patient. Our tool has the power to be a highly functional shared decision-making,” he argued.

Especially in a world where more care is equated with better care, educating patients and providers to make informed decisions can help improve the likelihood that patient care aligns with their values.   

“People still conflate more care with better care,” Cohen pointed out. “It’s important to educate them around this concept of more care being harmful.”