"Variation Among Individual Physicians: A Lever for Healthcare Cost Control With Untapped Potential' by Thomas H. Lee, MD

Twenty-seven physicians who work in an emergency department at a Boston Hospital see each other every day, and often care for patients within earshot of each other. How can it be that they vary as much as eight-fold in their use of CT scans of the head?

The fact is that everywhere one looks in healthcare, there is tremendous variation that just might offer opportunities to improve efficiency – as well as quality of care. This variation exists between regions of the country, and between groups of providers within any region. And this variation also exists among physicians within a single medical practice.

As Martha Bebinger recently reported on WBUR, the Eastern Massachusetts Healthcare Initiative (EMHI) is making a major push this summer to help physicians understand variation in their practices – e.g., how physicians vary in their use of high cost medications or procedures such as endoscopy. EMHI is a collaborative that includes the area’s major health plans and provider organizations, and our hope is that insight into which groups and which individual physicians are high utilizers of these drugs and procedures might help control healthcare costs.

There is good reason for optimism.

My colleagues at Partners HealthCare have been giving our physicians such data on their practice patterns for more than a year now, and we find that they really pay attention. If they use more x-rays than the other physicians in their specialty or in their practice – well, that makes them wonder if they should come closer to the norm, and think twice before ordering that test the next time they are seeing a patient with a low risk for serious problems. In general, we give physicians their data “unblinded” — so they can see how their colleagues are doing, and vice versa.

The goal is to create peer pressure for efficiency as well as quality. This “lever” for cost control – peer pressure – is one that is difficult for insurance companies to press. But we think it could be one of the most powerful levers out there. The reason – most medical decisions are made in a gray zone in which there is no clear right or wrong thing to do. Insurance companies can refuse to pay for a test or treatment when it goes against guidelines. But since there are no guidelines for most of the decisions that must be made every day in medicine, insurance companies have to defer to physicians’ judgments.

This is where EMHI and provider organizations come in. We are taking data from the payers, and the provider organizations are distributing it to physicians and then leading the exploration of what it means. If an insurance company sent these data to physicians, many doctors would ignore it. If the insurers published it on the Internet, physicians would be outraged about its statistical validity. But when the provider organizations are distributing it to physicians as a step in the exploration of opportunities to improve care, physicians pay attention.

It’s about six months too early for me to provide data on the impact of providing variation data to individual physicians at Partners – for now, let me just say that we are optimistic that it is helping improve our efficiency. And I’m glad that our payers and other provider organizations are going to be working together to distribute and think about our variation in the months ahead. We do compete, and we do have difficult negotiations – but one of the things I like most about Massachusetts is that we do find ways to work together when there is the chance to make the world a better place. Our collaboration on variation might just be an example of that collaboration.

Thomas H. Lee, MD
Network President, Partners HealthCare System