I “tagged” the following under “evidence of rational irrationality”:
-The U.S. Preventive Services Task Force, a government appointed entity presented in its new guidelines that women need not get regular mammograms until they’re 50 and older and that those specific self-exam instructions are no longer recommended. However, for reasons clearly based on emotions, the US Senate voted to not accept these recommendations. Does this mean that every potential policy backed with “clinical effectiveness research” will be either individually voted on or put up for endorsement by the Senate? Isn’t it a little odd that they would even vote on such a thing? While we can always point out the case of the woman under 50 who was saved by a mammogram, we can also likely point to cases where radiation and perhaps unnecessary surgery was done in by a mammogram. While EBP principles clearly show patient values as part of the equation, a “preventive” policy doesn’t mean that a mammogram can’t be done for those under 50–just means that it’s not recommended. What’s to stop the Senate from voting on changing the recommendation to 20 years old? For those that responded to my tweet about this I can only assure you that I don’t know a single person whose life hasn’t been impacted by cancer so my point on this issue not meant to be insensitive in that regard.
-The Republicans voted against cuts in home health care because they claimed it would hurt a lot of patients that need it. Their votes didn’t help as democrats defended and upheld them in an attempt to keep the cost of healthcare reform under 1 Trillion dollars. I would like either party to explain to me how you are going to expand benefits and expand beneficiaries and save money in the budget (something that White House Budget chief Peter Orszag apparently is starting to echo as well) or how this will lower costs of health insurance from employers which both the CBO and HHS secretary Kathleen Sebelius contend in their analysis.
Fortunately, my work week ended listening to a compelling presentation on value based reimbursement and episodic care from somebody who represents a payor perspective and experience in physical therapy claims.
Payors don’t really understand our outcomes instruments nor should they. If we can demonstrate that a patient’s care stayed “on protocol” this would provide an adequate proxy for outcomes. The burden for continuous self-improvement and evaluation for staying “on protocol” should fall to the provider who must maintain systems for assuring this “loop” which would further require implementation of evidence based practice and integration of research into practice. I can personally only think of a handful of protocols that can truly meet this outcome “proxy” but they are at least hi cost drivers in the system-notably acute low back pain and fall/balance. We might even see a “case” copay versus a per visit which would definitely place some added responsibility on the patient as they would naturally react to “under” treatment and “over” treatment which are the current repercussions of capitation (or low per visit/case rates) and fee for service environments.
Definitely, some interesting stuff.
Thoughts?
