Incentivizing Evidence-based Medicine
The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.
By Benjamin Kalinkowitz
October 30, 2017
Cost-effective, evidence-based care is the gold standard in health care policy and administration. Ideally, practitioners are guided by the most up to date medical research and they pursue only those interventions that have been proven to work. The time it takes to go from research to widespread clinical practice is unavoidable to some degree, but the difficulty of convincing the public that change is beneficial compounds the loss of money and positive outcomes. When treatment plans are guided by an image of the patient as a potentially litigious, hard to satisfy paying customer, with no policies to provide a counterweight and incentivize good medicine, evidence-based care often gets pushed to the wayside.
In my PT office, the scenario often looks like this:
Ms. Jones arrives complaining her rotator cuff has been bothering her. She tells me how the last time she hurt something, the physical therapist used this machine that made her feel better, and she hopes I can use that machine as well. The problem is the research on that machine shows that it’s benign, but ineffective as anything more than a placebo. However, many physical therapists still use the machine, whether because they haven’t kept up with advances in the field or because patients request it. Do I acquiesce, knowing that I am wasting her treatment time on something less effective, so I can keep her as a patient and continue with additional evidence-based treatments, or do I decline and risk losing her to another clinician who agrees to use the machine but may not improve her condition? Insurance will pay for the treatment she requests, so is the customer always right?
What about when the potentially ineffective interventions carry a societal cost? For example, while yearly pap smears are no longer recommended, a provider may choose to continue over-testing, “just in case.” The physician may accept the evidence and the recommendation from American College of Obstetricians and Gynecologists and the CDC, however, fearful of the risk of missing a cancer diagnosis, he or she may choose to continue the practice — and will still get paid for the test. While the stakes of a yearly pap may be relatively low, it becomes part of a larger problem of medical waste, leading to nearly a third of total health care expenditures on unnecessary tests and treatments. Similarly, a pediatrician may scientifically know that antibiotics are useless against a cold, but the parent in front of them “knows it helps.” The physician and the parent may both recognize the risk of antibiotic resistant superbugs, and how continued mis-prescription of antibiotics to humans and low level use in livestock are hastening the proliferation of these antibiotic resistant bacteria, threatening a century of medical advances. However, because these adverse outcomes seem remote, it can be easy to dismiss future problems in favor of easing today’s suffering.
There is another layer, of who my ultimate responsibility is to the patient and the patient’s freedom to interact with the free market to obtain the services they want, or to societal public health needs. In our free-market health care system, denying care for any reason is seen as curtailing the individual’s right to treatment. However, our system is in trouble because we cannot find the right balance between individual rights and the public good. While the consumer bears the direct cost, health care is not a consumable good. Individuals will make choices which seem benign but ultimately affect the health of those around them and the financial stability of the system. In order to provide evidence-based and cost-effective care, health care policy needs to incentivize good behavior.
Author: Benjamin Kalinkowitz, PT, DPT, MPA earned his Masters in Physical Therapy from Hunter College-CUNY, his Doctorate in Physical Therapy from the University of Kansas, and his MPA from the University of Nebraska at Omaha. Dr. Kalinkowitz has been a practicing physical therapist for 10 years, spending 8 years working at the Department of Veterans Affairs, and currently practices at an outpatient clinic in New Jersey. All views expressed are the author’s alone, and do not necessarily represent the Department of Veterans Affairs, the US Government, or his current employer
Twitter: @benkalinkowitz Email: [email protected]
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Incentivizing Evidence-based Medicine
The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.
By Benjamin Kalinkowitz
October 30, 2017
In my PT office, the scenario often looks like this:
Ms. Jones arrives complaining her rotator cuff has been bothering her. She tells me how the last time she hurt something, the physical therapist used this machine that made her feel better, and she hopes I can use that machine as well. The problem is the research on that machine shows that it’s benign, but ineffective as anything more than a placebo. However, many physical therapists still use the machine, whether because they haven’t kept up with advances in the field or because patients request it. Do I acquiesce, knowing that I am wasting her treatment time on something less effective, so I can keep her as a patient and continue with additional evidence-based treatments, or do I decline and risk losing her to another clinician who agrees to use the machine but may not improve her condition? Insurance will pay for the treatment she requests, so is the customer always right?
What about when the potentially ineffective interventions carry a societal cost? For example, while yearly pap smears are no longer recommended, a provider may choose to continue over-testing, “just in case.” The physician may accept the evidence and the recommendation from American College of Obstetricians and Gynecologists and the CDC, however, fearful of the risk of missing a cancer diagnosis, he or she may choose to continue the practice — and will still get paid for the test. While the stakes of a yearly pap may be relatively low, it becomes part of a larger problem of medical waste, leading to nearly a third of total health care expenditures on unnecessary tests and treatments. Similarly, a pediatrician may scientifically know that antibiotics are useless against a cold, but the parent in front of them “knows it helps.” The physician and the parent may both recognize the risk of antibiotic resistant superbugs, and how continued mis-prescription of antibiotics to humans and low level use in livestock are hastening the proliferation of these antibiotic resistant bacteria, threatening a century of medical advances. However, because these adverse outcomes seem remote, it can be easy to dismiss future problems in favor of easing today’s suffering.
There is another layer, of who my ultimate responsibility is to the patient and the patient’s freedom to interact with the free market to obtain the services they want, or to societal public health needs. In our free-market health care system, denying care for any reason is seen as curtailing the individual’s right to treatment. However, our system is in trouble because we cannot find the right balance between individual rights and the public good. While the consumer bears the direct cost, health care is not a consumable good. Individuals will make choices which seem benign but ultimately affect the health of those around them and the financial stability of the system. In order to provide evidence-based and cost-effective care, health care policy needs to incentivize good behavior.
Author: Benjamin Kalinkowitz, PT, DPT, MPA earned his Masters in Physical Therapy from Hunter College-CUNY, his Doctorate in Physical Therapy from the University of Kansas, and his MPA from the University of Nebraska at Omaha. Dr. Kalinkowitz has been a practicing physical therapist for 10 years, spending 8 years working at the Department of Veterans Affairs, and currently practices at an outpatient clinic in New Jersey. All views expressed are the author’s alone, and do not necessarily represent the Department of Veterans Affairs, the US Government, or his current employer
Twitter: @benkalinkowitz Email: [email protected]
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