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Project Measures 'Appropriateness' Of Medical Care In San Diego

August 23, 2012 1:13 p.m.


George McGregor, a health care administration who developed the Medical Appropriateness Project

Dr. R. Adams Dudley, Professor of Medicine and Health Policy at University of California San Francisco

Related Story: Schools Look To New Health Care Program To Cut Costs


This is a rush transcript created by a contractor for KPBS to improve accessibility for the deaf and hard-of-hearing. Please refer to the media file as the formal record of this interview. Opinions expressed by guests during interviews reflect the guest’s individual views and do not necessarily represent those of KPBS staff, members or its sponsors.

CAVANAUGH: This is KPBS Midday Edition. I'm Maureen Cavanaugh. San Diego schools are on the brink of a new semester, and as always, struggling against tight budgets. As part of the effort to reduce cost, both the San Diego teachers' union, and the Court board of education voted this summer to endorse a new program aimed at improving employee healthcare and reducing health costs. It's called the medical appropriateness project, the MAP program provides physicians providing necessary employee healthcare, and rewards employees choosing to go to those doctors. My guest, George McGregor is a healthcare administrator who developed the MAP. And Doctor Dudley, welcome, thanks for joining us.

DUDLEY: Thanks for having me.

CAVANAUGH: Give us some facts about the medical appropriateness project. Is MAP a healthcare?

MCGREGOR: No. Basically it's consumers that are buying healthcare, we had a lot of unanswered questions on the medical delivery system. With education budgets being cut back so significantly, and huge layoffs, with inflation being low, we were seeing medical premiums skyrocket 12-15% a year, and we had a lot of questions on why that was. When we started looking at what we were getting for our healthcare dollar, we find out through some studies that 1-5 of our diagnoses in our population were wrong, and 60% of the treatments for those that were correctly diagnosed were old treatments. So the experts came in and give us an estimate that we were spending $120 million a year treating diseases that our members in the population didn't have.

CAVANAUGH: So would that be -- I'm trying to categorize the MAP for our audience. Is this really a search project?

MCGREGOR: It starts with a research project, and clearly we're not medical people, and we're not qualified to make medical judgments. But you could use some pretty standard business techniques and statistical sampling in looking at the healthcare to find outliers, and the idea was to get physicians to go in and look at the outliers and say is that good or bad care and what can do you about it?

CAVANAUGH: How does MAP fit in with an employer's existing healthcare plan?

MCGREGOR: What it does, when you become a member, you agree to provide your medical claims information to a data warehouse, basically. A computer system designed to analyze the healthcare. We'll have a team of researchers that will go in and look for statistical anomalies in that healthcare. Then physicians go in and do charts on it and look at the care, and tell us was that good or bad care? If they come back and tell us this physician is really good, then we're going to market that physician's services and tell our members it looks like this would be a really good place for you to get your healthcare from, and we believe it will save money.

CAVANAUGH: What have you already found out about inconsistencies in healthcare treatment here in San Diego?

MCGREGOR: We have some very significant questions that we want to look at initially in the program. 55% of our deliveries, maternity, are scheduled, and on average, they're a week early. And that is a huge cost both in money, but also to the health of the mother and the baby to have them scheduled.

CAVANAUGH: You're talking about C-sections?

MCGREGOR: Correct. And it could be that the members are requesting as many of them as the physicians are. That's almost double the national average for that given procedure. The question is what's going on?

CAVANAUGH: When I first asked you about MAP, you started talking about how difficult it is for businesses to continue to maintain the costs of providing healthcare for their employers. Of the we often hear that healthcare is one of the biggest expenses that businesses face. How does MAP help lower the cost of providing health services? You are in the process of collecting this data. Are you also in the process of actually using this data to bring down those costs?

MCGREGOR: Yes. And three years ago, we went forward to look for what we could use as a quality measure to measure the quality of healthcare. The best measurement we found was out of the California office patient advocate. They measure on behalf of consumers 18 different areas of healthcare and medical group compliance. We felt if you have a higher compliance with approved medical protocol, that's a good pseudo measure for quality of care. So we built a specialized delivery system, built in incentive to move as much of our member care to those higher-scoring physician groups, and we submitted it to the actuaries that told us we could save about $12 million the first year. We actually came in and saved $20 million the first year, and $30 million the second year while we improved benefits. . The members actually got better care, less costly care, and higher quality care. So the next step is, that's a basic measurement, how do we get that information down at a physician level? Are expectation, one of our questions are, are we underpaying really good quality physicians and overpaying the average? And we think that's the case. We want to make sure we're rewarding those physicians that really do a good job on healthcare.

CAVANAUGH: Doctor Adams Dudley into the conversation, professor of health policy at the university of California San Francisco. And doctor Dudley, you came up with the rating structure that is crucial to this project. So how do you go about determining if a physician is providing appropriate or inappropriate care?

DUDLEY: Well, the main thing we do is we look at overall patterns of care and how things are different from average or from what's possible and known to be good. So as George mentioned, women having scheduled C-sections early before they reach term, and that's known to be bad for the woman and bad for the baby because sometimes they're just not ready yet. They're biologically not ready. And yet sometimes it has to happen. Sometimes -- we've all heard of premature babies. So sometimes you do have to do a C-section early. Just seeing one doesn't tell you anything. What you're looking for is a pattern of consistently doing C-sections well before you've reached the 39th week, which would tell you that there's something that needs to be looked into there.

CAVANAUGH: Doctor Dudley, we've heard the term evidence-based medicine, when doctors use the type of procedure with the best proven outcomes. Is your assessment based on that school of thought?

DUDLEY: Right. So what we're looking for when we go through the claims is for patterns that are not consistent with the evidence. And pretty much we do this focusing on places where the relevant specialty society has said you should do X or you should do Y. So the American college of obstetrics and gynecologist has said don't do C-sections on an elective basis in women before the 39th week of pregnancy. That's one of the reasons we're focusing there. In cardiology, don't put a stint in the patient's artery if they've got symptoms and no other indication. So we can look for that type of pattern.

CAVANAUGH: And some other common examples of treatments that are common place but not really appropriate have to do with prostate cancer; is that right?

DUDLEY: Right. So there are -- if may be hard for listeners to believe, but prostate cancer usually is a very slow-moving kind of cancer, and so it turns out that for people with what looks in the microscope like a low-risk prostate cancer, for those people, you don't get any benefit out of having an operation or having radiation, at least not in terms of living longer. And there have been studies now that have shown what's called watchful waiting, where you just treat the patient's other medical problems and only treat the prostate cancer if it causes -- blocking the urine flow, it just as quickly to lead to good outcomes as going in and doing surgery. But if you have surgery, you can have complications. And if the surgery cannot increase your chances of living longer, it's actually a bad thing for you to have the surgery.

CAVANAUGH: So would it be fair to say what you may be finding is that there is a tendency toward too much intervention?

DUDLEY: Definitely, definitely. That's a pattern that sets the United States apart from the rest of the developed world in terms of its healthcare. We have a tendency -- if there's something we could do, we have a tendency to just do it. And that ends up -- causing complications for patients and being quite a bit more costly.

CAVANAUGH: I'm interested, doctor, in how all this information that you're looking through is going to be used in connection with specific healthcare providers. I know that a couple of years ago, blue shield introduced physician ratings and got sued by the California medical association. I'm wondering how are doctors taking this idea of your looking through what they have been doing and the procedures and what they have been prescribe and sort of rating that as to whether it's any good or not.

DUDLEY: Well, it really matters what you're doing to try and rate them. So if a health plan comes along and says doctors, we're just going to count up how much you're costing us and rate you on that, then doctors are going to object because some doctors have sicker patients than others or older patients than others. I'm a lung doctor, and I pretty much only see people who already have some pretty severe lung problem that a primary care doctor wasn't comfortable handling by him or herself. So you know from the start that my patients are going to be different. So what we do instead is we focus on the kinds of measurements that the medical specialty itself has already said are the rate measurements to make. And evidence that they have already agreed with, and then we look for practice that's sort of out of the mainstream.

CAVANAUGH: What do you still need to accomplish to make MAP relevant in the California healthcare system?

MCGREGOR: The biggest challenge for us is how we affect consumer behavior. And educating our members that physicians aren't perfect, that medicine is an art, not a science, and how we are going to direct them to the high-quality physicians. There's a hesitancy to believe that you're recommending a doctor solely based on cost. So the biggest challenge is to engage the employees in making wise choices.

CAVANAUGH: So in other words, what you're saying, I don't mean to interrupt you, but I just want to see if I've gotten this clear. The idea is to convince the people who are a part of this program that they're not just being guided to a particular doctor because that's the cheapest doctor, or it's the cheapest hospital?

MCGREGOR: That's correct.

CAVANAUGH: And how do you do that?

MCGREGOR: We found in this population, the only thing that really motivates them is money and out of pocket cost. We will take the average quality healthcare providers and make them more expensive and provide better benefits at less cost to the employees for the higher quality, higher value providers.

CAVANAUGH: Do you need more people to be in this research project in order to get the statistics you need to actually present this to make this project go forward?

MCGREGOR: The more numbers that we have, the better the results are. We have enough critical mass now to move forward and begin the intervention on inappropriate care just with what we have. But if we're going to make population-wide assesses, we need to pretty much double our size, which is our goal in recruiting.

CAVANAUGH: I want to ask you both about how you see this ratings tool being used as part of healthcare reforms as they get fully implemented here in California. Doctor Dudley, have you been thinking about this in terms of the healthcare exchanges that we're expecting to open up in 2014?

DUDLEY: Well, in the exchanges and any insurers participating there, or even before the exchanges come on board, there's an opportunity for insurance companies to use this kind of information and create the kind of benefit structure that George is describing. So we'll charge you less if you go see the higher quality doctors is something that a health plan could do right now. There is in the law establishing the exchanges, there is also legislation enabling the government programs to do that, which until recently they couldn't do. So George is acting in a nongovernment program that can be aligned with a government program, and that brings more power to the program overall.

CAVANAUGH: Is that what you're aiming for with this?

MCGREGOR: Absolutely. We're concerned that there's going to be a shortage of quality physicians moving forward, and we can't really deal with the capacity issues. But if we can get people properly treated, get them out of the healthcare system because they're dealing effectively with the disease, then there'll be more room to cover those that don't have effective care currently.