Implementing a cost-containment or profiling program does mean big changes for ED physicians, says David Bolivar, MD, FACEP, Medical Director of Parkview Community Hospital in Riverside, CA. But, if the focus is on efficiency rather than cost-cutting, the results are positive for both the ED staff and the management.
"This is not just about saving money," says Bolivar, whose ED implemented EPMG’s Ambulatory Profiling Program three years ago. "It is about, What is the best test? What test can I do that will give me the best information.’"
Consisting of computer software that tracks and analyzes each physician’s ancillary procedures and medication orders and a cost-containment book that details treatment guidelines for the 20 most common complaints, the profiling program is designed to reduce costs in the 27 departments the physician practice group operates.
At Parkview, ED physicians meet monthly to review the current medical literature covering a specific complaint, with a physician assigned to cover each topic, Bolivar explains. The doctors then develop a consensus about which tests should be ordered, and when, and which tests are unnecessary.
For example, patients who present to their ED with an uncomplicated asthma attack are not routinely sent for a chest x-ray, a common practice in many departments, Bolivar says.
"If this person doesn’t have any predisposing factors, like he’s immunosuppressed or he has cystic fibrosis, we don’t do a chest x-ray, because the literature shows that most asthmatics have a normal chest x-rayso we don’t waste our time."
But the guidelines don’t stop there.
"What is the best we can do for this patient?" Bolivar asks. "Probably [give] a lot of bronchodilators and make sure he leaves the department with corticosteroidsthat is state-of-the-art and it is cost-effective because he is not going to come back later."
Another benefit of the new program is that it enhances the standardization of care in the department, he says. Because the physicians have agreed on a plan of action, a patient receives essentially the same care regardless of which physician treats him.
However, the department does not "micro-manage" each case, he notes. The physicians are evaluated when the computer data reports are run every three months.
Each physician is rated by a cost index that averages the number of procedures ordered by the doctor, the number of prescriptions written, and the acuity of the patients seen.
The physicians go over the data in group meetings, though each physician is identified only by number.
"We share the data, everybody knows what they are doing," says Bolivar. "Everybody has a number, but there are only eight of us here. We review the charts and say, Yeah, we screwed up, do better next time.’ Nobody gets offended."
If a physician is consistently an "outlier," meaning his or her data aren’t within one-and-a-half standard deviation from the rest of the physicians, Bolivar asks for the data on the physician’s utilization to be broken down by diagnosis.
In most cases, physicians order more tests when they are uncomfortable with a certain complaint, he says.
"I had one guy who was consistently high, and when I looked, I found that it was mostly on abdominal pain," he says. "Every time someone came to the hospital with abdominal pain, he ordered everything. It’s a difficult diagnosis, and you may need everything, but maybe he didn’t need to be ordering all of the tests [in each case]."
Bolivar says the answer to that problem is to become familiar with the current medical studies on that topic, develop a consensus about the best way to treat it, and then stick with it.
The physician in that particular case is now consistently within department parameters, Bolivar says.
"We all have our own practices and things we are afraid of," he notes. "I used to be terrified of kids, but in those days nobody bothered to gather any data. I probably ordered everything. A 2-year-old with a temperature of 104°that was a major disaster for me.
"I know some of my guys are scared of abdominal pain in a female, and they should be. But, you overcome those fears by becoming knowledgeable about what the literature says."
Because the procedures at Parkview are based on the latest studies published in medical literature and are discussed and adopted by everyone, the physicians know they will be able to show that they have met the standard of care, says Bolivar.
"You don’t find something abnormal and say, Oh, I could get sued over this,’" he says. "No, you follow the rules, and do the appropriate studies, and you will be OK. If nothing fits, you order a few more tests or you call for a consultant, and that’s probably the best way to proceed."
Though there was some initial resistance to the profiling program, most of the physicians are now accustomed to working within the framework, says Debbi Bervel, MD, FACEP, the department’s QI director.
"I think it’s been helpful at least as a guide to what we should be doing," she notes. "As long as we are doing it with acuity figured in."
When the profiling program started, patient acuity was not factored into the formula, she says. "If they [higher-acuity patients] are all you happen to see, then your data [will be] skewed."
The current program enables the department to keep physicians at the center of the norm for utilization, she says. If a physician comes up with high numbers, she and Bolivar will compare the numbers with the rest of the group, and then, possibly, pull some of the patient charts.
"We’ll say this is where we would have ordered this or not ordered that and bring them back more to the center," she says.
Most of the physicians are well aware of the need to document how they provide care, Bolivar says. But, in the rare instance that a physician doesn’t pay attention to how much money he or she spends, there is the "big carrot."
"The guys know that someday somebody’s going to say, Hey, you’ve got a doctor up there who’s twice as expensive as everybody else, we don’t want him,’" Bolivar says. "I have to fire him. Otherwise, I lose my job, [and] EPMG loses the contract."
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