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By Margaret M. Conner-Levin, MSW

Clinical practice patterns in the U.S. have always had great variance. Over the past 35 years, since The Dartmouth Atlas Study, research has documented great geographic variations in health care practices. These variances do not necessarily correlate with quality of care (see Improving Quality and Curbing Health Care Spending: Opportunities for the Congress and the Obama Administration). These issues are magnified for consumers with complex care conditions and chronic conditions—with often unstudied complications of comorbid conditions and unmet social support needs.

This variance, and how actual service delivery varies from clinical guidelines, has always been of concern to policymakers—because of the implications for quality of care and cost. Two recent changes in the health and human service delivery landscape are bringing new attention to clinical practice patterns and clinical guidelines. The first is the move to include financial risk in the reimbursement contracts of health plans, health systems, and provider organizations—particularly risk that is focused on reducing duplicative and unnecessary care delivery. The second is the addition of consumers with behavioral and cognitive conditions, and consumers with more complex social support needs, to these risk-based and value-based contracting models.

The challenge is one of incentives. In fee-for-service (FFS) and cost-based reimbursement models, while there was significant variance in clinical practices, there was only a financial incentive to provide too many services to consumers. As we move to more financial risk borne by health plans and provider organizations, the financial incentives skew to providing too few services. While “over treatment” is not great for consumers, “under treatment” can be life threatening.

I think this means we can’t continue to separate clinical practice guidelines from risk-based and value-based reimbursement models. When the management team of an organization develops rates for any type of alternate payment model, they make assumptions about the needs of the consumers they will serve—and the number and types of services those consumers will use. Essentially, the clinical practice guidelines become part of their pricing methodology. And, if the payers don’t specify the clinical guidelines to be used, the organization will use their own clinical guidelines as assumptions in that rate development.

The results of the disconnect around clinical guidelines are bubbling up in press coverage and lawsuits (see To Improve Consumer Care In Medicaid & Beyond: Define Value & Make It Public and Judge Rules United Behavioral Health Medical Necessity Criteria More Restrictive Than Accepted Standards). I think this conflict will continue and grow more acute. The Patient Protection & Affordable Care Act (PPACA) requires health plans to publish their clinical guidelines (see H.R. 3590: Patient Protection & Affordable Care Act of 2010). Are they easy to understand or specific enough about clinical decisionmaking? Take a look at these examples:

  • UnitedHealthCare’s clinical guidelines for the treatment of bipolar disorder refer clinical professionals to the American Psychiatric Association’s practice guidelines (see Clinical Guidelines: Bipolar Disorder (Adults))
  • Aetna’s clinical policy for the treatment of Autism Spectrum Disorders (ASD) relies on information from the American Academy of Child And Adolescent Psychiatry and the National Academy of Sciences and outlines specific services that may be included in treatment and assessment (see Autism Spectrum Disorders)
  • Cigna’s clinical practice guidelines for the treatment of depression refer clinical professionals to the American Psychiatric Association’s practice guidelines for the treatment of depression and the U.S. Preventive Services Task Force guide for screening for depression (see Cigna HealthSpring Clinical Practice Guidelines)
David Young

The question is how to get clinical practices in sync with the emerging VBR models. When I asked my colleagues, the consensus was the financial incentives that go beyond cost reductions are critical—as well as public performance data that is available to consumers, advocates, and clinical professionals. OPEN MINDS Senior Associate, David Young noted:

States and sometimes the Feds talk about quality care but in reality, health plans and provider organizations provide ‘legally’ acceptable care; they meet the terms of the contracts. Despite what that means to end users, that care is what we get.

OPEN MINDS Senior Associate Ken Carr went on to talk about incentivizing consumer outcomes and quality of care. He noted:

Ken Carr

I agree that commonly accepted standards of care, or those standards included in contracts, may not represent “best practice” outcomes, especially for unique situations. With most politically charged issues like this, understanding the root causes of what causes unacceptable results is key. It is easier to blame bad people and organizations—and they do exist. But the issues are often a result of how resources flow, who has the power to make decisions, and whether fair, efficient processes (with an element of compliance) have been established.

The question is what the best approach for is driving results—implementing strict regulatory controls or aligning funding with incentives to motivate and empower results.

From a value-based perspective, aligning how resources flow to motivate health plans and provider organizations to achieve agreed upon results—care coordination, integrated services, consumer access, for instance—has been shown to deliver results. There are many examples of how this incentivized approach has increased quality services and driven down service costs. I like the concept of making health plan and provider organization results public because transparency addresses the compliance element. While we will always need regulations and compliance committees for those who lack ethical behavior, transparency of results motivates most of us (health plans and provider organizations alike) who really want to do the right thing for the consumers that we serve.

“Standards of care”—medical necessity, clinical appropriateness, social/legal necessity, consumer entitlement, community standards—are certainly not agreed upon across the health and human service field. But, even with agreement on a set of clinical guidelines doesn’t end the challenges for consumers. Published guidelines don’t necessarily change clinical practice patterns and the clinical decision support tools needed to do just that are not in common practice. As we see more “pay for performance” across the health and human service systems, managers of every organization will be looking for tools to measure clinical practice variance in their own organizations—and tools make the use of “best practices” the rules, rather than the exception.

For more on the current state of value-based contracting with health plans, join OPEN MINDS Senior Associate Deb Adler on August 12 for her seminar, How To Build Value-Based Payer Partnerships: An OPEN MINDS Executive Seminar On Best Practices In Marketing, Negotiating, & Contracting With Health Plans.

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