Observation Deck: Is Less More?

Two news stories from the past month caught my attention. Perhaps they offer hope for a way out of what appears to be a collision course for U.S. medicine – that is, Americans’ expectation of the healthcare system and their inability to pay for it.

The first came from the National Committee for Quality Assurance, a non-profit organization that develops healthcare evaluation tools, including health plan accreditation, physician recognition and organization certification. NCQA announced that more than 100 physicians and chiropractors nationwide had committed to be evaluated under NCQA’s new “Back Pain Recognition Program,” which is intended to recognize healthcare providers who deliver top-quality care to patients with lower back pain. Back pain is one of the most common ailments in America, according to NCQA. And it’s one of the most expensive; treatment costs total approximately $91 billion a year and accounts for 25 percent of all workers’ compensation claims.

NCQA believes that top-quality care to patients with lower back pain often means less care. During the first six weeks of a back pain episode, evidence shows that physicians should advise most patients to resume normal activity within a few days, according to NCQA. What’s more, absent other clinical indications, doctors and patients should also avoid unnecessary X-rays and other imaging services during this initial period of care. Studies have found that as many as four in 10 imaging studies associated with lower back pain are unnecessary, and up to two-thirds of all epidural steroid injections are avoidable – with no significant differences in healthcare outcomes as a result, according to the organization. NCQA’s evidence-based guidelines for care of such patients could result in savings of at least $205 per patient per year in direct medical expenses, it says.

The second news story was just as fascinating. One IDN – Geisinger Health System in Danville, Pa. – is guaranteeing its workmanship and charging a flat fee for certain procedures, including 90 days of follow-up treatment. In other words, even if the patient suffers complications and needs re-hospitalization or other care because of those complications, Geisinger will not send the insurer another bill. So, rather than make the patient (or, more likely, the insurer) pay for more procedures, even if they are necessitated by mistakes or bad care the first time around, Geisinger is putting itself on the line by guaranteeing its work. Presumably, the end result will be better – and perhaps less – care.

We’ve been here before. Managed care was supposed to reward caregivers for delivering less care. But the concept was discredited because Americans didn’t like the thought of receiving less care, and the HMOs could be, well, a bit inelegant in their pursuit of cost-savings. So, will these new plans fare any better? Will Americans be content with toughing out back pain for a couple of months to see if it subsides on its own, rather than getting MRIs and maybe even a spinal fusion? Will providers be willing to stand by their work and eat the cost of their mistakes? Is less more?

There’s a certain sense in which these dogfights over healthcare funding are like World War II dogfights between fighter planes in the sky. The rest of us are resigned to watching the battle unfold above us, preparing to run for cover if a flaming wreck should scream our way. Some argue that no amount of money is too much to pay for our health. Others argue that our healthcare system is so convoluted that money is going down the drain or into the pockets of people who don’t necessarily have the patient’s best interest at heart. Big questions like these aside, contracting professionals can and do play a huge role in healthcare quality and healthcare economics by doing what they do best – watching the technologies coming into their facilities and helping providers and administrators extract the most value from them.

About the Author

Mark Thill
Mark Thill is the Editor of The Journal of Healthcare Contracting and has been reporting on healthcare supply chain issues since 1985. He is a graduate of Dominican University in River Forest, Ill., and he received a master's degree in journalism from Northwestern University in Evanston, Ill.