We continue to enhance our delivery of value by increasing quality and lowering costs and our focus is shifting to the clinical appropriateness and consequently, the clinical variability amongst physicians. Clinical variability can be defined as the difference in spending on patients that have similar health characteristics treated by different physicians. As we begin to compare the different treatment practices amongst providers, assurance of similar quality care and outcomes is paramount.
A recent study in JAMA reviewed the cost of treatment in hospitalists and found a 40% difference in spending on similar patients. They also examined the quality outcomes and discovered there was no difference. Choosing to review the actions of hospitalists minimized selection bias.
Why is there so much variability in costs? We need to delve into the possible reasons for the differences. With medicine being simultaneously an art and a science, biases and influence drive physicians in how they practice. In a significant way, training affects how we act. If during our informative years we learn from mentors who believe in the need to collect a tremendous amount of information before making a diagnosis and treating, we are likely to replicate those activities throughout our careers. Even when we confront newer information and evidence, old habits tend to die-hard.
No doubt, our personalities play a significant role as well. For instance, one might postulate if my practice style is more aggressive in comparison to my colleagues, then I will tend to have higher costs because my tendency will be to want to know all possible information regarding a potential diagnosis. Besides, if I believe my primary job is to prevent harm at the individual level regardless of what I do and that is how I define success; I will tend to rule out all possibilities of situations that might be detrimental to the patient’s health regardless of the likelihood of occurrence or cost. On the flip side, if my focus is on a larger population and I am concerned about resources and finances, I will consciously think differently about my spending habits and maybe less about all possible potential outcomes as I contemplating multiple factors in my decision making.
Furthermore, there is also a chasm from the cost perspective of what we do. Most physicians do not know the cost of the services delivered or even the relativity of one treatment modality versus another. Our incentives, both financially and our perception of our vocational goals are not aligned to focus on the cost components of our treatment.
If our goal is to decrease clinical variability, we will need to address all these underlying drivers of performance; bias, training and education and potential outcomes. Merely exposing one to the issue will not be enough. Understanding the root causes of the problem in each person we wish to impact is our imperative. As we continue to study the issue, we must focus on exploring why there is variability. This means a much more in-depth focus on understanding the psyche of those enabling the outcomes. Delivering quality care to those we serve is the calling of nearly all providers. Comprehending what is both under the surface and the bigger picture will support our ability to influence change.