By Emmy Ganos, Michael Parchman, and Brian Austin
Much about the immediate future of health care is uncertain, but one trend is clear—the push to encourage value-based care is ongoing. Many payers and purchasers in the public and private sectors continue to emphasize the importance of pursuing value-based payment agendas, and at the Robert Wood Johnson Foundation, we are continuing to work toward ensuring that everyone gets the highest-value care possible as a critically important factor in building a national Culture of Health. In the paper Taking Action on Overuse: Creating Conditions for Change we present a framework to guide the engagement of health care leaders, providers, and patients as active partners in overuse reduction efforts.
Taking action on overuse may be one of the most effective mechanisms for improving quality while reducing costs, and ultimately improving the value of care delivery. And, reducing low value care is something that individual health professionals, care teams, and the administrators and leaders who support them have the means to take action on, to contribute to a higher-value health system.
The Choosing Wisely initiative has been tremendously effective at raising awareness of the problem of overuse, and in providing educational resources for practitioners and patients. But making progress on actually reducing the utilization of low-value services is an ongoing and difficult challenge. Practice patterns are built over a lifetime of practice, habits can be hard to change, and heuristics that are taught as part of the hidden curriculum suggest that more care is both better and safer. All of this means that taking action on overuse requires a culture change in how medicine is practiced.
The literature on reducing overuse, while growing, is still fairly nascent. We do know that multi-component interventions work best, but there are few tools beyond educational resources that can help innovators and clinical champions guide the transformation and culture change required in their own organizations to address overuse of low-value services.
We know that incentives matter, but we also know that behavior change is far more complex than simply tweaking bonus structures (See Rich, 2016). Harnessing providers’ intrinsic motivation to provide the best care for patients is likely needed—but how can we do that in a health care culture that emphasizes “doing as much as you can” for your patients, and which measures “productivity” in RVUs?
The MacColl Center for Health Care Innovation within the Group Health Research Institute was the ideal group to explore these questions. As the organization that created and disseminated the Chronic Care Model, their team has decades of expertise in front-line transformation, but even for them, this issue of “how do we encourage, rather than just dictate, doing less?” was a unique challenge because of how overuse issues are perceived by health care professionals.
Through our partnership with MacColl, we conducted a literature review and an environmental scan to understand how leading health care organizations have tackled this challenge, and learned a great deal about the ingredients in successful transformation efforts. As anticipated, the importance of engaged leadership, the sharing of timely and relevant data, and appealing to the professionalism of providers were all cited multiple times. Less anticipated was the frequent evocation of the role of conversations—opportunities to share stories and speak frankly with peers, team members, and finally with patients. These conversations don’t happen without the time, the structure, and the training to hold them. Our respondents described how important it was to coach leaders in how to facilitate conversations that felt safe, but that also created opportunities for critical reflection, to acknowledge that current practices may be harmful to patients. At one organization, their mantra to help achieve this was “no data without stories, no stories without data.”
Insights like these form the basis for our framework describing the conditions that can support the culture change necessary for providers, teams, and patients to take ownership of overuse.
To create this framework, we partnered with ABIM Foundation and Choosing Wisely, who graciously joined our technical advisory council (TAC) and helped us to learn from some of the most effective implementation efforts of the Choosing Wisely campaign. We explored the tremendous Value Transformation efforts underway at University of Utah to understand how engagement drove that effort. We heard about the importance of simultaneously addressing providers’ beliefs and behaviors from the University of Vermont Medical Center. And Sutter Health shared an “aha” moment in presenting provider level data demonstrating practice variation to a group of specialists in his organization: “First they were curious about it, then they began laughing and kidding each other about it, then they turned to the guy who was doing it better and asked him, ‘How do you do this?’”
It has been a fascinating journey to explore these topics with the MacColl team and an esteemed TAC over the last few years. Our published article Taking Action on Overuse provides the basic roadmap for health care leaders and health professionals to plan interventions that are well-suited to their own institutional priorities and cultures.
We have more to learn about how to best support these changes in organizations, and have launched a new project with UCLA, Swedish Hospital System, and Missouri Primary Care Association, in partnership with expert practice coaches, to help build out and refine these concepts. We look forward to building a set of implementation tools to accompany our change package, which others can use to plan and implement their own unique approaches in their own organizations. We invite you to follow our progress on our website www.takingactiononoveruse.org, and send us stories you may have on fostering a culture change to increase engagement in your own systems and contribute your thoughts on the Taking Action on Overuse framework as we venture together into a new era of health system transformation.
Emmy Ganos, Robert Wood Johnson Foundation
Michael Parchman, Kaiser Permanente Washington Health Research Institute
Brian Austin, Kaiser Permanente Washington Health Research Institute