Reform Update: Docs being called to use more effective treatments

Physicians could do far more to use prescription drugs more cost-effectively—in some cases, by recommending exercise or better nutrition before prescribing them in the first place, say a team of Dartmouth University researchers. The researchers are calling for more nuanced measures of prescribing performance that can be tied to physician compensation as part of payment reform.

Dr. Nancy Morden, an associate professor at the Dartmouth Institute for Health Policy & Clinical Practice, and Dartmouth professors Dr. Lisa Schwartz, Dr. Elliott Fisher and Dr. Steven Woloshin, say that widely used measures of quality do too little to encourage physicians to use the most effective therapies or treatment options. “As insurance coverage expands, we must ensure that greater access to prescribing drugs confers better health, not harm,” the authors wrote.

The authors cite five examples of measures that could be adjusted and improved, including treatment of mild hypertension. Diet and exercise can be used to treat patients with a new diagnosis of mild hypertension, they wrote, and performance metrics should give doctors an incentive to go that route first before falling back on drugs, a strategy the authors called “accountable prescribing.”

The performance measurements should specify the order in which doctors prescribe competing drugs to treat the same condition, based on a ranking of research for outcomes and safety. When confronted with more than one appropriate option “cost can be an appropriate tiebreaker,” they wrote.

New efforts to tie payment to quality performance could incorporate such a strategy, the authors wrote.

Currently, physicians who hit quality targets for blood pressure or diabetes measures are rewarded without any regard for how the target was met, even when physicians bypass options that have better overall clinical results, lower costs or fewer risks, the Dartmouth doctors wrote in the New England Journal of Medicine. “Medications are the quickest and easiest way to reach the goal.”

Prescription drugs account for about 10% of U.S. healthcare spending. Retail sales of drugs to treat high blood pressure, diabetes and other ailments are projected to total $283.7 billion this year. And with the nation's largest insurance expansion in decades starting in January, spending on prescriptions is projected to soar 8.8% in 2014, federal actuaries say.

But not all of that spending is necessary, and prescription drugs have long been recognized as one source of potential savings in the nationwide effort to curb healthcare cost growth. One recent report by the IMS Institute for Health Informatics estimated the cost of prescription drug misuse to be $200 billion last year.

Closer attention to drug costs could be added to quality measures used by the one of Medicare accountable care experiments, the Shared Savings Program, the Dartmouth authors wrote.

Evolving quality measures present a critical challenge to efforts to more closely tie payment to performance, Morden said in an interview. “Efficient, meaningful quality measures are hard to develop, and this is just a start,” she said.

Modern Healthcare's third survey of accountable care organizations found that many ACOs track measures of care coordination, such as the rate at which patients are readmitted to the hospital, or the percentage of vulnerable patients who receive support from care providers after leaving the hospital. ACOs that responded to the survey reported a wide variety of care coordination measures. ACO leaders said their use would evolve with more experience. Medicare ACOs were among the 37 ACOs to participate in this year's survey.

State officials in California, New York, Oregon and other states have approved Medicaid managed-care companies to sell health plans to non-Medicaid shoppers in state insurance exchanges, Modern Healthcare reported this week. As M.P. McQueen reported, approval in several states opens a new market to the Medicaid insurers. Insurance exchanges are scheduled to begin operation in October and will serve as a marketplace where low-income households can buy commercial insurance with subsidies available through the Affordable Care Act.

Follow Melanie Evans on Twitter: @MHmevans