Can Peer Comparisons Help Rein In Runaway Health Care Costs?

There is a golden opportunity awaiting the podiatric profession. This opportunity has already provided significant quality improvement in other medical specialties. Please take a minute to read this blog and pass this information on to the current leaders of the American College of Foot and Ankle Surgeons (ACFAS) and the American Podiatric Medical Association (APMA).

I just finished reading the book The Price We Pay: What Broke American Health Care – And How To Fix It, written by Marty Makary, MD.¹ Makary is a best-selling author who also happens to be a surgeon and Professor of Health Policy at Johns Hopkins University.

The Price We Pay is about what drives up consumer costs in today’s American health care system. In short, Makary identifies three main areas of concern:

1. Unethical pricing and collection strategies by most hospitals across the country
2. Middlemen who broker insurance benefits to employers, pharmacy benefits to employers and medical supplies and devices to hospitals
3. Overtreatment of patients by physicians

I was most interested in the section discussing overtreatment as I have observed this same trend not only in podiatry but across many medical specialties over the past 30 years. The concept of overtreatment may include the practice of recruiting patients from seemingly legitimate sources, ordering a plethora of diagnostic tests and instituting treatments that may or may not have any real benefit to the patient.

Makary and his team at Johns Hopkins University have access to all Medicare data regarding diagnostic testing and medical services, and can track which doctors order and perform these services. He wanted to use this data to see if it could identify certain “outliers” within a medical specialty who might be billing for too many procedures on a patient, or who might be performing unnecessary surgery.

Our country spends over 15 billion dollars a year measuring and evaluating “quality” of care delivered by physicians and hospitals.² Makary points out that these quality metrics focus primarily on complications after treatment such as infection or readmission to the hospital. Up until now, no studies on quality have examined if the initial treatment was really necessary. Makary directed his team at Johns Hopkins to begin evaluating appropriateness of care rather than cost of care or quality of care, which is only based on after-care complications.

How One Study About Physical Therapy Prior To Spine Surgery Collected Vital Practice Data

To begin his study of appropriateness of treatment, Makary started with spine surgery performed on Medicare patients. He learned from respected spine surgeons that most patients with back pain do not require surgery and many will resolve their symptoms with physical therapy. The prevailing body of research and standard of care dictates that most patients (other than trauma patients) should have physical therapy before undergoing spine surgery. Makary asked a simple question: How many spine surgery patients in America have at least one physical therapy treatment before undergoing surgery?

This was a relatively simple study as Medicare data will show any physical therapy billing as well as surgical billing specific to a patient undergoing spine surgery. Using this methodology, Makary found that the majority of patients undergoing spine surgery in the United States do, in fact, have physical therapy before resorting to surgery. However, he discovered a small but significant number of spine surgeons who were “outliers” in that they never prescribed physical therapy for their patients prior to surgery.

How One Study About Patterns In Mohs Surgery Led to $18 Million In Medicare Savings

To see if this data could actually change practice patterns, Makary teamed with the American College of Mohs Surgery (ACMS).³ As you probably know, Mohs surgery is a subspecialty of dermatology, focusing on precise removal of cancer tissue in the office or clinic setting. This specialized surgery and tissue examination is reimbursed based upon each biopsy or each unit of tissue block examined. Typically, Mohs surgeons remove between 1.2 and two tissue blocks per patient over the course of a year. Makary found a small but significant group of outliers who used an average of three to four blocks per case. He worked with ACMS to come up with a method of notifying the outliers in hopes they would consider changing their practice pattern. They agreed to use simple education rather than discipline to affect this change.

Instead of disciplining or notifying only the outliers, the ACMS provided the national data to all of their member Mohs surgeons, letting them know where they stood relative to their peers in terms of practice pattern. This is similar to what utility providers do when they show you each month what your electrical or water consumption is in comparison to your neighbors. The doctors were not told that they did too much Mohs surgery. Rather, when they do these procedures, the doctors were told how they performed in comparison to their peers and the number of tissue blocks billed to Medicare per patient over a one-year period.

The results of the program were almost instantaneous as billing volume for tissue blocks dropped significantly over the following months. The program, which cost $150,000 to implement, provided a savings to Medicare of over $18 million dollars in its first 18 months after the intervention. All of these positive results were obtained by the simple sharing of information with physician providers and no disciplinary action or other repercussions against any of the member of ACMS. This self-imposed improvement is similar to the corrective action any of us would take if we were informed that our yearly consumption of electricity was double that of our neighbors.⁴

A Closer Look At ‘Improving Wisely’ And Assessing The Appropriateness Of Care

Makary started a program called Improving Wisely, which would provide metrics to many different medical specialties.⁵ His team studied patterns of individual doctors’ performance and evaluated appropriateness of care. This was a departure from current methods to measure “quality” of medical care, which only focuses on complications after treatment. Instead, Improving Wisely focused on whether the treatment ever should have been performed in the first place. Up until now, researchers had not assessed data for these types of practice patterns, which cause waste in health care. It is a challenging endeavor with many potential negative consequences. Good doctors could unfairly be labeled as bad ones. Some doctors can appear as outliers simply because they treat more complex patient populations.

Improving Wisely is not necessarily telling doctors that they do too many procedures or order too many diagnostic tests. Instead, it looks at whether physicians are following proper protocols prior to ordering the test or performing the procedure. The Improving Wisely project has been very successful in reducing unnecessary procedures while improving the standard of care within many medical specialties. One reason is that the project worked with each specialty college or academy to include thought leaders in the process of determining which metrics would be most valuable in detecting overtreatment or unnecessary procedures. The initial specialties and procedures studied included GI procedures and numbers of biopsies, cardiac valve replacement versus repair, pediatric umbilical hernia surgery and the use of chemotherapy in patients who have reached end-of-life stages.

Understanding The Potential Benefits Of Peer Comparison In Practice Patterns

In 2017, the American College of Phlebology (ACP) launched a collaborative quality improvement initiative with the Improving Wisely project, looking at practice patterns of the treatment of venous disorders.^6,7 This collaborative effort was reported in Vein magazine by Margaret Mann, MD.⁶ Dr. Mann articulates to the ACP members the benefits of peer comparison of practice patterns:        

“Harnessing the power of comparison feedback and peer education to inspire changes in physician behaviors is at the core of the Improving Wisely pilot program. The program is based on the concept that transparency through peer comparison reduces unnecessary variations, which in turn leads to improved patient safety and quality of care while also reducing costs.

It works on the premise that all of us physicians are acting in the best interest of our patients and driven to provide quality care. Without national standards and benchmarking tools, many of us may operate our entire career without knowing how we perform next to our peers. By providing confidential, individualized reports, Improving Wisely provides a collegial educational opportunity to help identify physicians who are unaware of their variations and bring their performance back into the norm.”

Could Peer-To-Peer Comparison Have An Impact In Podiatry?

I assume that podiatric physicians are at the low end of the spectrum of health care providers in terms of potential to affect the cost of health care in this country. Our specialty is not even mentioned in Makary’s book. On the other hand, orthopedic surgeons are discussed frequently and Makary quotes a study suggesting that over one-third of knee replacements performed by this specialty are unnecessary.⁸

With these findings in mind, multiple studies could and should be undertaken to evaluate the appropriateness of care within the podiatric profession. The results will undoubtedly improve our standing within the entire medical profession and within the general consumer-patient population. I am certain that podiatric physicians and surgeons will measure up very favorably in comparison to other specialties if researchers utilize the criteria used by Improving Wisely to study podiatric treatment patterns.

Previous professional organizations have invested in participating in the Improving Wisely program to improve quality and reduce medical costs. These societies are much smaller than podiatric organizations. The American College of Mohs Surgery has 1,600 members and the American College of Phlebotomy, now called the American Vein and Lymphatic Society, has 2,000 members.^3,6 With more than 7,600 members, the American College of Foot and Ankle Surgeons should have the resources to collaborate with Improving Wisely to develop a peer-to-peer data transparency program to monitor and improve consistency in practice patterns, improve quality and reduce overall health care costs.⁹

For example, similar to spine surgery, there are several foot and ankle conditions that one can favorably treat with physical therapy so podiatrists can avoid surgery most of the time with these conditions. Perhaps one could evaluate certain surgical procedures billed to Medicare, looking at whether clinicians referred to physical therapy preoperatively or not. Logical research questions could include: Which patients received physical therapy prior to a plantar fasciotomy, Achilles tendon debridement or lateral ankle ligament reconstruction?

Even when the decision to perform surgery is appropriate, did the physician follow the standard of care in terms of procedure choice and appropriateness of overall billing by the doctor to Medicare? Similar to the study of the number of tissue blocks per Mohs procedure, we could look at the number of pieces of hardware or the type of hardware the surgeon used in the procedure. Then there could be further study into practice patterns among doctors and the cost of the most common procedures. For example, when comparing all the foot and ankle surgeons in the country, what is the average cost of hardware utilization for each hammertoe procedure or bunionectomy procedure?

We should recognize the positive results already achieved by Makary’s team at Johns Hopkins with the Improving Wisely project. The success of the program is based on the fact that physicians actually like to know where they stack up in comparison to their peers in terms of the cost of their services. Many have reported that they proudly showed their patients that their own performance was equivalent or better than most of their peers. In the end, providing high quality appropriate care was a primary commitment we all made to our patients and to ourselves when we graduated from podiatric medical school. 

Dr. Richie is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. Dr. Richie is a Fellow of the American College of Foot and Ankle Surgeons.

References

1. Makary M. The Price We Pay: What Broke American Health Care – And How To Fix It. Bloomsbury, NY: Bloomsbury Publishing; 2019.
2. Casalino LP, Gans D, Weber R, et al.  US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff. 2016;35(3):401-406.
3. American College of Mohs Surgery Website. Available at: https://www.mohscollege.org/. Accessed October 3, 2019.
4. Albertini J, Wang P, Fahim C, et al.  Evaluation of a peer-to-peer data transparency intervention for Mohs micrographic surgery overuse.  JAMA Dermatology. 2019. doi: 10.1001/jamadermatol.2019.1259. Accessed October 3, 2019.
5. Improving Wisely Website. Available at: https://www.improvingwisely.org/#! . Accessed October 3, 2019.
6. Mann M. Improving wisely pilot program: harnessing the power of peer to peer feedback to improve quality, safety and value. Available at: https://www.veindirectory.org/magazine/article/industry-updates/improving-wisely-the-power-of-peer-comparison-feedback. Accessed October 4, 2019.
7. Improving wisely study highlights utilization in vein care: what are key takeaways so far? Available at: https://www.phlebology.org/improvingwiselyhighlights . Published September 24, 2019. Accessed October 4, 2019.
8. Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States:  a multi-center longitudinal cohort study.  Arthritis Rheumatol. 2014;66(8):2134-2143.
9. American College of Foot and Ankle Surgeons. Defining ACFAS. Available at: https://www.acfas.org/Member-Center/Inside-the-College/Defining-ACFAS/. Accessed October 4, 2019.