Paying more wisely: effects of payment reforms on evidence-based clinical decision-making

Lake, Timothy; Rich, Eugene C.; Valenzano, Christal Stone; Maxfield, Myles

doi:10.2217/cer.13.27

Cited by 10 publications

(7 citation statements)

References 24 publications

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“…33,34 While fee-for-service payer incentives encourage greater provision of services and, at the other extreme, capitation discourages overuse of services (but possibly encourages stinting on care), no single payment system-even those with incentives tied to quality measures-consistently incentivizes greater use of evidence-based care. 35,36 Tying reimbursement to quality metrics (for instance through pay-for-performance programs) might logically encourage evidence-based clinical decisions, but there is inconsistent evidence on the effectiveness of this approach, which is limited by available quality metrics and the threat that overly prescriptive metrics could divert attention and resources from other more productive means of providing high quality care and undermine physicians' intrinsic motivation to provide high quality care. [37][38][39] Extrinsic incentives that conflict with intrinsic rewards of clinical practice may be less effective than those tailored to meet both intrinsic needs of the clinical staff and extrinsic needs of the organization.…”

Section: Physician Organizationsmentioning

confidence: 99%

“…The maladjustment of fees across various services has been identified as key driver of deviations from evidence-based clinical decision making. 35 A host of other public policies at the local, state, and federal level (e.g., regulations, price setting, support of medical education) could also directly or indirectly influence physician clinical decision making. 12 …”

Section: 43mentioning

confidence: 99%

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Factors Contributing to Variations in Physicians’ Use of Evidence at The Point of Care: A Conceptual Model

2015

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There is ample evidence that many clinical decisions made by physicians are inconsistent with current and generally accepted evidence. This leads to the underuse of some efficacious diagnostic, preventive or therapeutic services, and the overuse of others of marginal or no value to the patient. Evolving new payment and delivery models place greater emphasis on the provision of evidence-based services at the point of care. However, changing physician clinical behaviors is likely to be difficult and slow. Policy makers therefore need to design interventions that are most effective in promoting greater evidence-based care. To help identify modifiable factors that can influence clinical decisions at the point of care, we present a conceptual model and literature review of physician decision making. We describe the multitude of factors-drawn from different disciplines-that have been shown to influence physician point-of-care decisions. We present a conceptual framework for organizing these factors, dividing them into patient, physician, practice site, physician organization, network, market, and public policy influences. In doing so, we review some of the literature that speak to these factors. We then identify areas where additional research is especially needed, and discuss the challenges and opportunities for health services and policy researchers to gain a better understanding of these factors, particularly those that are potentially modifiable by policymakers and organizational leaders. 5 Many studies have observed large variations in clinical practice, across geographic areas and within local areas or even specific physician organizations. 6 We are undergoing rapid change in healthcare organization and delivery. Physicians are increasingly practicing in larger organizations and systems of care, in part prompted by widespread initiatives by federal, state, and private payers to improve care quality and lower costs. These reform efforts, such as patient-centered medical homes and accountable care organizations, along with significant federal funding of comparative effectiveness research, incentives for adoption of health information technology that includes decision support, and feedback on clinical quality performance raise the hope and expectation that clinical decision making will improve, with greater adherence to accepted evidence.Within this context, research and requisite data collection on key factors affecting physician decision making is necessary to design interventions and refine current ones. In this article, we present a conceptual framework for understanding factors contributing to physician clinical decision making, specifically those related to physicians' use of evidence at the point of care. With this framework, we conclude with directions for future research and the data needs necessary to conduct this research.We frame our discussion in the context of physician decision making as part of a broader inquiry into collecting data on physicians and their practice organizations. Of course, evidence...

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Section: Physician Organizationsmentioning

confidence: 99%

Section: 43mentioning

confidence: 99%

Factors Contributing to Variations in Physicians’ Use of Evidence at The Point of Care: A Conceptual Model

2015

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“…Thus, one cannot assume episode-defining diagnoses are correct or procedures appropriate. 25 Moreover, episode-based approaches to measuring output do not value work done to avert future episodes (for example, prevention and chronic disease management).…”

Section: What Are the Outputs From Physician Work?mentioning

confidence: 99%

“…35 36 Some quality measures can be calculated through claims, but the associated limitations have been well documented, 28 and the appropriateness of few services or surgical episodes can be determined without more detailed patient-level data. 25,28 Even patient surveys combined with all-payer claims data would prove insufficient for reliable measurement of physician outputs across specialties and settings.…”

Section: Measuring Outputsmentioning

confidence: 99%

Measuring Changes in the Economics of Medical Practice

et al. 2015

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“…4 Given the implementation of bundled payments and other payment reforms, the use of evidence to improve care coordination and standardization also is becoming increasingly important for hospitals and health care systems. 5 Clinician time and expertise to critically appraise evidence and conduct synthesis has been noted as a barrier to implementing evidence-based medicine in health care settings. [6][7][8] Although external organizations can produce evidence reviews, the applicability and timing of those reviews is not always ideal for local settings.…”

mentioning

confidence: 99%

Implementation of an Evidence-Based Care Program Within a Multihospital Health Care System

2018

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The need for evidence-based guidance at the local hospital level is challenged by lack of clinician resources to critically appraise and synthesize evidence, and the applicability and timing of external evidence reviews are not always ideal for local settings. BJC HealthCare established an Evidence-Based Care (EBC) program to address evidence synthesis needs within the organization using a standardized rapid review process. From 2012 to 2016, 377 rapid reviews were completed. Common review topics included supplies or technology (23%), infection prevention (20%), and patient safety (18%). The median turnaround time for reviews was 22 calendar days (16 business days). Of the 68% (28/41) of review requestors who responded to a survey, 89% agreed or strongly agreed that EBC's review informed their project or final decision, and 93% indicated that they likely would request a review in the future. Using rapid review methodology, an EBC program delivered timely and relevant evidence for local decision making.

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Paying more wisely: effects of payment reforms on evidence-based clinical decision-making

Cited by 10 publications

References 24 publications

Factors Contributing to Variations in Physicians’ Use of Evidence at The Point of Care: A Conceptual Model

Factors Contributing to Variations in Physicians’ Use of Evidence at The Point of Care: A Conceptual Model

Measuring Changes in the Economics of Medical Practice

Implementation of an Evidence-Based Care Program Within a Multihospital Health Care System

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