Put to the test

It’s a familiar scene in the Enloe Medical Center emergency room: Amid a crush of patients, arriving in various conditions with various ailments, an on-duty physician enters an exam room to find someone wholly new to the hospital.

There’s no medical record to reference nor personal history with the patient upon which to draw. If the symptoms don’t suggest a textbook diagnosis, what’s the doctor to do?

Order tests.

The battery is almost routine. Depending on the circumstances, the physician may rattle off orders for a CT scan, MRI (magnetic resonance imaging), blood-chemistry panel, EKG (electrocardiogram) …

“We kind of throw everything and the kitchen sink at them,” said Mike Wiltermood, Enloe’s CEO, describing the situation. “Emergency rooms are zoos; the doctors are trying to see as many people as they can during certain times of the day, especially, and certain days of the week.

“You’re greeted by an emergency room physician who really doesn’t have your history and then [for hospitalization] you’re admitted by a hospitalist who doesn’t have your history—so, in my mind, it’s just a recipe for ordering more tests than might be required for somebody’s care when you don’t have that information.”

Enloe is by no means unique in facing such challenges and liberally performing labs.

Doctors routinely order tests on hospital patients that are excessive—ones that reviews have deemed unnecessary, even wasteful. The Lown Institute, a nonprofit promoting change in the health system, estimates at least $200 billion gets wasted annually in the U.S. on excessive testing and treatment. This overly aggressive care also can harm patients, generating mistakes and injuries believed to cause 30,000 deaths per year, according to a report in the BMJ (formerly the British Medical Journal).

There are plenty of opportunities to trim waste in America’s $3.4 trillion health care system—but it’s often not as simple as it seems.

Sutter Health thought it had found a simple solution: The Sacramento-based health system deleted the button physicians used to order daily blood tests.

“We took it out and couldn’t wait to see the data,” said Ann Marie Giusto, a Sutter Health executive.

The number of orders hardly changed. That’s because the hospital’s medical-records software “has this cool ability to let you save your favorites,” Giusto said at a recent presentation to other hospital executives and physicians. “It had become a habit.”

Hospitals are feeling pressure to change.

Three of the state’s biggest health care purchasers have banded together to promote care that’s safer and more cost-effective. The California Public Employees’ Retirement System (CalPERS), the Covered California insurance exchange and the state’s Medicaid program, known as Medi-Cal—which collectively serve more than 15 million patients—are leading the initiative, dubbed Smart Care California.

That dovetails with the Choosing Wisely campaign, a national effort launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation. The group asked medical societies to identify at least five common tests or procedures that often provide little benefit.

The ABIM campaign, also backed by Consumer Reports, encourages medical providers to hand out wallet-size cards to patients with questions they should ask to determine whether they truly need a procedure.

Daniel Wolfson, chief operating officer at the ABIM Foundation, said the Choosing Wisely campaign has been successful at starting a national conversation about unwarranted care.

“I think we need massive change and that takes 15 years,” Wolfson said.

In California, at least, frustration hovers.

“The changes that need to be made don’t appear unrealistic, yet they seem to take an awful lot of time,” said Dr. Jeff Rideout, chief executive of the Integrated Healthcare Association, an Oakland nonprofit group that promotes quality improvement. “We’ve been patient for too long.”

Progress may be slow, but there have been some encouraging signs. In San Diego, for instance, the Sharp Rees-Stealy Medical Group said it cut unnecessary lab tests by more than 10 percent by educating both doctors and patients about overuse. A large public hospital, Los Angeles County-University of Southern California Medical Center, eliminated preoperative testing deemed superfluous before routine cataract surgery; as a result, patients on average received the surgery six months sooner.

Enloe, which has integrated Choosing Wisely into its quality improvement initiative process, also has reduced testing.

Since the start of 2016, the hospital has performed 21 percent fewer CT scans of the cervical spine and 56 percent fewer CT scans of the lumbar spine—the latter especially significant since each lumbar CT exposes the patient to radiation equal to 66 X-rays. Enloe also has decreased the amount of inpatient lab tests by 40 percent over that period.

“It’s an example of what we can do when we get together and agree on a protocol—and physicians lead that,” Wiltermood said. “Nobody has to feel like they’re shortchanging their patients; they’re providing the care that’s reasonable and safe, and they’re being responsible with respect to the resources.”

Sutter has incorporated more than 130 Choosing Wisely recommendations as part of a broader effort to reduce variation in care. In all, Sutter said, it has saved about $66 million since 2011.

That’s a significant sum. However, during the same period, Sutter reported $2.7 billion in profits. Last year alone, it posted an operating profit of $554 million on revenue of nearly $12 billion.

Giusto said her team of employees tasked with changing physician behavior and eliminating these variations is separate from administrators who are focused on maximizing reimbursement. She said there can be conflicting forces within a hospital.

“We get real excited about a project with [emergency department] doctors on reducing CT scans for abdominal pain,” said Giusto, director of Sutter’s office of patient experience. “Then I can hear the administration say that was a fee-for-service patient; I just lost money, right?”

Enloe, like the other hospitals in Butte County, predominantly treats patients on public insurance. That is a different payment model entirely. Medicare, for instance, pays a flat fee for a patient’s hospitalization, Wiltermood explained, which gives hospitals a disincentive to provide more services. Plus, laws prevent doctors from receiving pay linked to ordering tests, prescribing drugs, etc.

“Regardless of the payer mix, hospitals and physicians have every incentive to just do the right thing for their patients,” Wiltermood said. “Maybe we’ve got some habits that have to be rethought.”