Medicine under scrutiny: Employers are looking to evidence-based medicine—that is, quantified research on treatment patterns and outcomes of health care services and procedures—as a way to help control costs

Risk & Insurance, April 1, 2002 by John Otrompke

While many employers who provide health benefits to their employees may think of the scientific method as a facet of medicine that dates back almost to the Hippocratic oath, the past few years have seen the growth of a new theory in the health care industry called evidence-based medicine (EBM). The EBM phenomenon was spurred by a 1999 report issued by the Institute of Medicine called, "To Err is Human," which documented preventable medical errors as the fourth-leading cause of death in the United States. This report prompted efforts by legislators, policymakers, leading employers and others to create new initiatives to reduce medical errors and improve health care quality in general.

"There's almost an incredulousness on the part of many employers that a lot of medicine is practiced without any scientific basis at all," says Michael Bailit, president of Bailit Health Purchasing LLC.

Bailit is the producer of one of two new initiatives in the area of EBM coming out now. Bailit has published a report on 11 new ways of compensating health care providers to improve health quality. The report is being produced by the National Health Care Purchasing Institute. The other effort is the ongoing work being done by the Leapfrog Group, an EBM-advocacy organization founded in 2000 by the Business Roundtable, sponsored by Fortune 500 employers such as GE, GM, Verizon, and the Pacific Business Group on Health, as well as the Centers for Medicare & Medicaid Services (CMS). Leapfrog, which is advocating for three important measures that could universally improve quality, is also compiling a voluntary national online survey, which currently lists information from 300 hospitals on how they've implemented the three "leaps."

"Over the next couple of years, we plan to have a comprehensive database," says Suzanne Delbanco, executive director of Leapfrog. The group has grown from seven members to more than 100 in less than two years, emphasizing the importance of EBM to large employers.

Besides the new offerings by the Institute and Leapfrog, there are a wide variety of other tools employers can look to make sure they are getting the most quality, and the fewest preventable accidents, for their health care dollars. Semipublic organizations such as the Joint Commission for the Accreditation of Health Care Organizations and the National Committee on Quality Assurance accredit organizations on various criteria or offer a database of information on providers and health plans. The concept has spawned a veritable growth industry in the analysis of how providers can improve quality. Although derided in the medical community as "cookbook medicine," clinical practice guidelines give providers standards for the treatment of common illnesses, particularly in the area of chronic disease management.

As simple as the concept sounds, evidence-based medicine grew out of the realization that, for all the scientific basis for much of modem medicine, much of what is going on in the field today is done without the benefit of proof in the form of clinical studies, articles in peer-reviewed journals, or formally quantified research or comparison of any kind. Quantified study of treatment patterns can have real implications for cost control as well as outcomes. For example, a prescription for a slightly more expensive, newer antidepressant can reduce system costs elsewhere because depression is associated with chronic illness, and effectively controlling the depression tends to improve treatment compliance, studies have shown.

Three Great "Leaps"

The Leapfrog Group places great emphasis on its three measures for quality performance. Though the IOM report initially produced a large number of quality improvement suggestions, these three have been most thoroughly tested. "We commissioned a report by the Dartmouth Medical School to study the economic impact of adopting the three practices. Overall, they found adoption could save the health care system as a whole $9.7 billion dollars," says Delbanco.

The three leaps are computerized physician order entry, which studies suggest could reduce serious medication errors by 86 percent; intensive-care unit staffing by specialists known as "intensivists"; and evidence-based hospital referral, an area where employers may have more than average control.

"This last suggestion is based on the idea that patients who need high-risk surgeries or neonatal care should choose hospitals based on publicly reported, risk-adjusted data; because the data is not always available, we're using volume as a proxy," says Delbanco. For example, she says, the suggested minimum volume for a coronary artery bypass graft is 500 procedures per year.

Other tools are also available to help employers select a health plan that has a relationship with the right hospital. Leapfrog is releasing data from hospitals drawn from a sample of six areas of the country. "Employers often look to the National Committee for Quality Assurance or use existing tools such as HEDIS off the rack," says Kip Piper, director of the National Health Care Purchasing Institute. "But because of politics and the visibility of managed care in the 1990s, health plans were held to a high standard of visibility, while the provider community was allowed to remain invisible. Consumers started to use provider retention as their only standard for quality, whether beneficiaries could use any provider they want," Piper says.