The Hidden Story Behind the Development of Evidence Based Guidelines or, Why It is So Hard to Reduce Health Care Spending Trends
Almost a year ago now, new guidelines on mammography screening were released by the U.S. Preventive Services Task Force (USPSTF). The new guidelines updated 2002 recommendations, and based on recent research recommended against routine screening of women ages 40-49. Instead of routine screening, the USPSTF concluded that the decision about screening women 40-49 should be left up to individual women and their physicians based upon individual risk profiles.
The new guidelines immediately sparked a firestorm of debate that essentially accused the government of putting money concerns ahead of women’s lives. Indeed, the debate was so heated that it became embedded in the larger discussion about health care reform. Some said that if health reform passed, it would result in “terrible” decisions like the revised guidelines (aka, death panels). All sorts of politicians came forward with plans that would limit the ability of insurers and others to implement the guidelines as written.
This debate underlines the challenges we face in America in controlling health care spending. The whole idea that “more is better” is almost universally embraced in our culture and our views of health care utilization, coming into direct conflict with our stated desire to “bend the health care cost curve.”
Now two colleagues at the University of Michigan and the Michigan Veterans Administration, Kerianne H. Quanstrum and Rod Hayward, have written a very important thought piece on this issue in the New England Journal of Medicine: “Lessons from the Mammography Wars.”
Quanstrum and Hayward point out the reality that guidelines often cannot be precise black and white determinants of care. While there are some combinations of procedures and patient characteristics where guidelines leave little doubt about the right course of medical care, there are many other cases where the right course of treatment is more equivocal and patient preferences need to be taken into account.
Quanstrum and Hayward further point out that the process often used today to develop guidelines has a serious flaw: guidelines are generally developed by the clinicians who most stand to benefit from the use of the procedures in question. Thus, according to the authors, it was breast radiologists who were most vocally opposed to the new mammogram guidelines, and breast radiologists who have the most at stake financially from these guidelines.
As a society, we like to see physicians as somehow immune to financial incentives. In that context, we tend to see doctors as entirely different from other small business owners. But that view is both mistaken and dangerous. Physicians in private practice (the majority of physicians in this country) must act like small business owners: to do otherwise would be folly. They have to pay their staffs, maintain their offices and earn incomes. Even though they have gone into a “helping profession,” there is nothing inherently different about the character of physicians from the rest of us that would make them unresponsive to opportunities to influence their own finances.
As physicians, Quantrum and Hayward have called out something that we should be aware of and address in the light of day: the need to develop guidelines within a structure of checks and balances so those who have the most to gain financially are not the ones making guideline decisions. Quantrum and Hayward’s approach calls for a structure somewhat akin to that used by the Preventive Health Services task force, where clinical but more general experts lead guideline development.
Quantrum and Hayward’s recommendations are essential if we are to use our resources more wisely, especially as millions more get health insurance coverage. But changing the system for developing guidelines is only one piece of the puzzle, as we saw in the mammography example. Doctors aren’t the only ones who have to buy into a new way of doing things. The rest of us: the non-experts, non-clinicians, aka, patients must also understand and support this approach.
Any clinician who perceives financial harm from a clinical recommendation to do less is likely to complain – loudly – and try to enlist their patients to do so as well. If we are not on board with two things: (1) more care is not necessarily better care, and (2) motives should be questioned when those arguing for more (or less) care have financial incentives to do so, we had better be prepared for ever-increasing health care spending. Without a doubt, we will never, ever be able to fundamentally address health care spending without embracing these two premises.