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Advancing High-Value Health Care: A New AJM Column Dedicated to Cost-Conscious Care Quality Improvement


Despite the very high cost of health care in the US, expenditure continues to rise. According to the Centers for Medicare & Medicaid Services, health care expenditures for 2016 are projected to be $3.4 trillion, and the percentage of the gross domestic product spent on health care will increase from 17.4% in 2013 to 19.6% by 2024.1 In 2009, the Institute of Medicine (now called the National Academy of Medicine) estimated that approximately $750 billion spent on health care was “wasted on unnecessary services, excessive administrative costs, fraud and other problems.”2 Berwick and Hackbarth3 subsequently estimated in 2012 that the percentage of health care spending that is wasted could be as high as 47%, with the upper limit of wasted health care dollars totaling well over $1 trillion. Most concerning is that the financial burden on patients has forced many to forgo health care,45 and that medical bankruptcy is now the primary cause of bankruptcy in the US.6

To address exorbitant costs and in recognition of wasteful practice, medical practice is transitioning from a volume-based reimbursement model to a value-based model, with an emphasis on reducing the utilization of unnecessary tests, procedures, and treatments.7 In 2012, the American Board of Internal Medicine Foundation’s Choosing Wisely campaign8 called national attention to the importance of avoiding wasteful medical diagnostic tests and treatments. Evidence-based recommendations for reduced utilization have been submitted by more than 70 medical societies, inspiring providers around the world to reflect on their practice patterns and work toward reducing low-value practices. For the Choosing Wisely campaign to effectively reduce utilization, practitioners must operationalize the recommendations. Best practice guidelines have existed for years, but they have not effectively curbed high levels of utilization,9 driven by decades of diagnostic and therapeutic innovation, long-standing learned behaviors, concerns about missed diagnoses, and fear of liability.10

Guidelines alone will not reverse this momentum. Medicine needs a “disruptive innovation,”11 a force that increases the accessibility and reduces the cost of an expensive commodity. In this case, what is needed is a focus on high-value health care. Disruptive innovation of health care can be accomplished if medical institutions systematically implement quality improvement initiatives to reduce unnecessary practice, evaluate outcomes to confirm that diagnostic and therapeutic efficacy is not compromised, and share results through publication, meeting presentations, and other means of dissemination.

Investigations must determine which interventions, including educational campaigns, clinical decision support in the electronic medical record, and provider performance feedback, most effectively refine practice.121314Successful innovations must be sustainable, maintain efficient workflow in the clinical setting, and avoid information overload that physicians face with e-mail, best practice alerts in the electronic medical record, social media, and professional Internet resources. Studies comparing the relative contributions of different interventions provide useful guidance in designing future value-improvement initiatives. For instance, Zuckerberg et al12reported on a campaign to eliminate the standard practice of administering 2 units of blood (“why give 2 when 1 will do”) that successfully reduced red blood cell utilization by 14% a year, for an annual cost avoidance of $462,440. The intervention began with an education campaign, consisting of Grand Rounds presentations and quarterly comparative provider ordering feedback, which was effective in decreasing red blood cell utilization. Subsequent addition of clinical decision support embedded in the computerized physician order entry did not result in any additional reductions in utilization, although they noted the potential importance of embedding clinical decision support in the computerized physician order entry for sustaining reductions in red blood cell transfusions.12


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-Pamela T. Johnson, MD, Amit K. Pahwa, MD, Leonard S. Feldman, MD, Roy C. Ziegelstein, MD, David B. Hellmann, MD

This article originally appeared in the June 2017 issue of The American Journal of Medicine.

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