Matt Modleski on Evidence Based Medicine

OurBlook interview with Matt Modleski, vice president of Stovall Grainger Modleski, Inc., health care consultants.

Please describe what you mean by evidence-based medicine.

MM: Evidence-based medicine (EBM) means using the best available external clinical guidance as well as the relevant experience of the medical provider to provide the best available care following the most proven methods available.

What are the pros of it?

MM: The pros of it are simply where evidence exists that a specific medical protocol yields a positive result, it makes sense to follow that protocol until something is proven to be more effective. The easiest place to see how this works well is when you have a throat culture that comes up positive for strep. The evidence says an antibiotic should be prescribed to kill the infection. This is an easy example and one that many people have experienced. The less precise the diagnosis, the less evidence there is to prescribe a known solution.

Here is an oversimplification that will make providers cringe but may help your readers make sense of it all. When a certain diagnosis codecauses your check engine light to come on in your car, once you have the code downloaded, it is pretty easy to get the right part changed the first time. If I merely started changing what I thought would be best based on my experience, I may change the wrong part and get a much worse result than if I had followed the best path forward based on the downloaded code. Once again, it is an oversimplification to compare cars and humans, but where we have precise diagnoses, the protocol followed should be based on the best evidence available.

Another benefit of EBM is that as diagnoses become more and more precise, we can and should use lower cost providers to deliver the care that the evidence suggests. This is a very contentious issue where “fee-for-service” medicine is practiced because every patient who sees a lower cost provider takes money from the higher cost provider further upstream. Closed systems like Kaiser and Intermountain Health have worked to align incentives to make that lower cost provider the best choice when a diagnosis is precise enough to permit it.

What are the cons?

MM: As I mentioned above, EBM works well when the diagnosis is precise. It does not work well when tried in an environment of non-precision or what we’ll call “intuitive medicine.” When faulty guidelines are established or weak guidelines are put in place in the realm of intuitive medicine, then innovation is stifled and new therapies may actually be slower in getting to patients. Our reimbursement system delivers “fixed pricing” and a “fee-for-activity” system that doesn’t pay based on results. These fundamental issues make forcing change to EBM very difficult.

Even when it’s been established that a diagnosis is precise enough to follow established guidelines, here are just a few of the challenges to more fully implementing EBM:

How fast will evidence change, who will establish the protocols and who will pay for the clinical trials? Who will say what level of evidencerequires a switch to a new protocol? These are just a few of the "devils in the details" components of switching to a care delivery system that relies more on evidence than what we use today.

You have said only 5-7 percent of current healthcare in America is evidence-based. Why is it so low, and would there be a significant impact on the U.S. healthcare system if it were implemented much more widely?

MM:  The few challenges I’ve captured in my answer to the previous question detail a few reasons why EBM’s use is so low, but the two most prominent reasons are that the healthcare delivery system isn’t set up in a strategic fashion designed to take advantage of “new evidence,” and the “fee-for-activity” system of reimbursement doesn’t incent behavior that would drive the uptake of EBM. I’m not going to address the latter subject of reimbursement, but I do want to elaborate on the lack of strategic focus in our care delivery system.

Think about the average hospital ... they do a little of everything and many things they don’t do very well. Since they are non-focused (non-strategic) in the care they provide, they will always have tactical resource deployment that is less than optimum. For example, if as a hospital I do a bit of everything, it’s an overwhelming administrative task to stay on top of changes in evidence and innovation for everything I do each day. It’s also impossible to streamline our training, our purchases and our staffing to deliver excellent results because of that lack of focus. Here is where meaningful changes are taking place today, but we need to accelerate these changes quickly.

The Service Line Approach to delivering care in hospitals is a more strategic focus and does bring clinical excellence to specific service lines, like cardiac care, women’s health, orthopedics etc. Once those service lines have been established, and results are measured and tracked, it’s much easier to drive the adoption of EBM because everyone is focused on the same measurements and using established protocols to achieve their results. It’s not perfect but it’s a huge step in the right direction.

Again, I don’t want to oversimplify the issue for your readers, but think of having your car worked on. If you drive a Ford, when it breaks and has to go to the dealer, do you take it to GM or to Ford? Why wouldn’t you take it to GM? The answer is because they are trained to work on GM’s, not Fords. If there was a change in the Evidence Based Guidelines used to fix Fords, who would know the most about the change, Ford or GM? Obviously it would be Ford. This same type of focused approach in smaller subsets of healthcare delivery can yield better adoption and utilization of EBM.

Of course the next step beyond service lines are Integrated Practice Units that focus exclusively on one type of service line. MD Andersen in Houston is an IPU and only concerned with one service area, the treatment of cancer. It doesn’t take long to see how a provider who has narrowed their focus to achieve efficiencies and excellence in clinical results is best positioned to not only use EBM, but deliver a great deal of the “new evidence” through the clinical trials that many of these institutions are involved in.

One last point; if you’re thinking that the entire hospital delivery system as it stands will have to be reorganized to transition from the “we do everything” world to more strategic delivery of care, you are correct. That’s why healthcare reform that’s packaged in a “bill” vs. a 10-year plan will yield much higher costs to all of us and not address any of the main causes of our bloated healthcare spend.

Does the reform legislation now before Congress carry provisions for evidence-based medicine and if so, are they adequate? If not, what should be added?

MM: I haven’t read all of the many pages of all the various bills in Washington, but I can tell you the government-run board (Comparative Effectiveness Board) that President Obama wants to utilize mirrors the government entities in Europe that do the same thing. Essentially, this board measures cost and clinical effectiveness and makes a determination on whether or not a product will be allowed on the market and reimbursed.

I think there is a role for a board like that ... only it should be composed of doctors, insurers, CMS and citizens, not just government employees. BC/BS has been very outspoken about the need for such a joint commission/body, and if there is going to be a better uptake of EBM, then there needs to be a viable way to aggregate and evaluate all of the changes in medicine in terms of their overall value to the patient.

How does evidence-based medicine affect the legal malpractice problem that plagues healthcare providers?

MM: Where precise diagnoses exist and the providers know about them, most would tell you they feel compelled to follow the guidelines for two reasons. The first is to avoid being sued, the second is to facilitate getting paid.

For example, oncologists today who embark on an “I’m going to do it my way” mentality may find themselves unable to recover the cost of very expensive chemotherapy drugs to the tune of tens of thousands of dollars. Providers will also tell you that evidence based guidelines increase their “hassle factor” immensely as the insurers require the provider to chart “the reason” they’re not following the established guidelines even if clinically they have a legitimate reason not to follow it.

With prescribed treatment plans for various diseases, it almost sounds that there could be no deviations. Is that true, and if so, how can U.S. healthcare improve if new and different treatments can't be used?

MM: Please see my comments about the difference between EBM utilization where diagnoses are precise vs. places where intuitive medicine is still required. The real challenge in maximizing the uptake of EBM will be designing a more strategic care delivery model that realizes EBM only works in “precision” medicine and not expecting it in the areas of “intuitive” medicine.

We should have a clearer break between the two business models (precise vs. intuitive) and that means completely overhauling the current hospital system and associated outpatient clinics. As long as we leave the precise areas of medicine co-mingled with the intuitive areas of medicine, the adoption of EBM will be an administrative nightmare.