I recently received a notice in the mail that I was not being listed as a preferred provider for one of the major insurance companies. The rating was done based on how your clinical practice compares with national and specialty specifc measures for quality and with local cost-effciency benchmarks in the same geographic region. At frst I was quite upset as my competitive nature got the best of me; how could I not be better and more effcient than the other urologists in the area? I had passed the outcomes area which made me (and I am sure my patients) feel relieved but was just below average in the cost-effciency area thus preventing my listing as a preferred provider. In simple terms, my patients were doing well but overall I was spending slightly more for similar diagnoses than other urologists in the area.
This should not have surprised me as academic urologists tend to see a higher complexity of cases which may require more resources. I then went into the methodology used for the designation and appeals process. The appeal process allows the clinician to review all the patients seen and what the cost effciency for each patient was. It also allowed for a way to exclude patients who were costly outliers due to circumstances such as terminal care or multiple simultaneous diagnoses. For me, this was the frst time that I looked at such specifc data on cost and outcomes for each patient that I had treated. Most interesting was how extremely costly some patients were and I looked in more detail. Many of the patients were more costly for obvious reasons such as hospice care or unrelated complications. However, I found myself questioning whether I really needed robotic assistance to do that radical nephrectomy on Mr. Jones or whether the prostate MRI on Mr. Smith really helped with the management of a 69-year-old with an elevated PSA.
To date, we have heard about accountability for our practice patterns and outcomes but have not met with any consequences for missing the mark. The insurance companies have gathered this data for years but for the frst time it hit me that this data is going to utilized more frequently and forcefully as we move forward. In this case, the penalty for not making the mark was merely not being listed as a preferred provider by the insurance carrier.
The amount of money in healthcare is going to be limited and urologists and other clinicians are going to have to take an active role in prioritizing resources. We can get angry that we are being monitored or can constructively realize that there are many things that we can do to improve the quality and costs of delivering medical care. Using such data to change practice patterns is inevitable and we need to take an active role in making good practice decisions. If we do not make these tough decisions, then ultimately others will make them for us. Better that we are in control of how we practice medicine to get the best outcomes while maintaining a semblance of cost effciency. The alternative may not be so great if we allow those who do not practice medicine to dictate our patterns.
Thomas W. Jarrett, MD
The George Washington University
Washington, DC, USA
© The Canadian Journal of Urology™; 20(6); December 2013