In the last JailMedicine post, I introduced the subject of Utilization Management (UM) in Corrections. To some, Utilization Management has earned the reputation of being too focused on money and not enough focused on patients. But after I had been doing UM for awhile, I had an important insight that changed the way I thought about Utilization Management and (I believe) made my own efforts at UM much more effective.
That key insight is this: That which is expensive in medical practice is bad medicine. The way to control costs in medicine is to reduce or eliminate bad medical practice. Cost containment is simply a happy byproduct of this endeavor. When UM physician advisors work with primary care practitioners, the conversation should center around best medical practice, not money.
To illustrate this, consider three outcomes of a proposed medical treatment for a patient. This treatment could be a drug, a surgery, a C-pap machine—or any therapy at all, for that matter.
The first outcome could be that the patient improves as a result of the treatment. The antibiotic cures the pneumonia. The patient no longer has biliary colic after gall bladder surgery. The C-PAP machine allows the patient to experience effective sleep. In all of these cases, the patient benefited and the treatments were a wise use of medical dollars.
In the second case, the treatment leads to no benefit to the patient. The patient has a viral chest cold–not pneumonia–and so the antibiotic does nothing. A back pain patient still has back pain after spinal surgery that was supposed to relieve the pain. After getting a CPAP machine, the patient decides that he does not like it and so the machine sits, gathering dust, in a corner of the bedroom. In each of these cases, the money spent on the therapy was wasted. We could have achieved a similar result by simply burning the money we spent on these worthless therapies in a campfire.
In the third case, the therapy actually harms the patient. Not only was the original money wasted (because the patient received no benefit), but more importantly, we now must throw good money after bad in an attempt to clean up the damage done by the first therapy. The antibiotic given for a viral illness causes the patient to have diarrhea (Augmentin does this in 1 out of every 6 patients)—even worse, the diarrhea is a case of C. difficile that plagues the patient for years. The back pain patient not only has no pain relief after surgery, but actually complains of more pain and now uses a cane. The CPAP patient trips over his unused CPAP machine and breaks a hip.
Of course, when we prescribe a therapy today, all of these potential consequences are in the future. How can you know today what effect a particular treatment will have, good or bad, when they have not happened yet?
Well, the wrong answer is to say “No one can predict the future so I’m not going to even try to anticipate what my prescriptions may do.” In fact, through research, we actually can do reasonably well at predicting the potential outcomes of many medical procedures and therapies. If the potential adverse effects of a medical therapy outweigh the potential benefits, well, we should not be prescribing that therapy. Such a therapy is not only bad medicine, but a waste of money, as well.
One group that is trying hard to get the word out about medical interventions have no medical utility is the “Choosing Wisely” campaign (found here). Their mission statement reads “Advancing a national dialogue around avoiding unnecessary medical tests and treatments.” To this end, they asked each medical specialty society to come up with medical tests or interventions that are commonly done but have no medical utility.
Here are a smattering of examples:
- Don’t use expensive medications when an equally effective and lower-cost medication is available (American College of Preventative Medicine). This recommendation is the basis of all correctional formularies.
- Don’t do PAP smears on women who have had a hysterectomy for non-cancer conditions (American College of Family Practice).
- Avoid ordering a knee MRI for a patient with anterior knee pain without mechanical symptoms or effusion unless the patient has not improved following completion of an appropriate functional rehabilitation program (American Medical Society for Sports Medicine).
- Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin (Society of General Internal Medicine).
- Avoid CT of the head in asymptomatic adult patients with syncope, insignificant trauma and a normal neurological evaluation (American College of Emergency Physicians).
- Don’t prescribe oral anti fungal therapy for suspected nail fungus without confirmation of fungal infection (American Academy of Dermatology).
This stuff is UM gold!
To these let me add two of my own Choosing Wisely recommendations:
- Don’t order a test if you don’t care about the results. Believe it or not, this happens all of the time! Ask yourself what you are going to do if the test is positive and what you are going to do if the test is negative. If you are not going to do anything different whether the test is positive or negative, then the test is worthless and a waste of money. Don’t do it!
- Don’t send a patient to a specialist until you have completed the basic patient evaluation yourself. As an example, if a patient complains of rectal bleeding, don’t refer to GI until you have yourself done a rectal exam, a stool Guaiac and appropriate labs.
That’s just good medicine!