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A Critical View of Low-Value Medical Care

A Critical View of Low-Value Medical Care

Traditionally, the value of medical care has been determined by the effectiveness and safety of a given intervention, regardless of that intervention’s cost. The current goal is to provide the highest-value solutions that are effective, safe, and have the lowest possible cost, according to Craig A. Umscheid, MD, MSCE. “Low-value diagnostic and therapeutic interventions waste patient and prescriber time and money and can even be harmful,” he says. “Low-value care takes away time that providers could be delivering high-value care.” Contributing Factors Defensive medicine practices can be a significant contributor to low-value medical care (Table 1). For example, providers may order diagnostic tests because they are fearful of malpractice suits if there is even the slightest chance that patients could have a disease or condition, says Dr. Umscheid. He discussed his experiences with low-value medical care as a patient in JAMA Internal Medicine. “The healthcare system often supports low-value versus high-value care,” he says. “Physicians who see many patients per day in order to make enough revenue to support their staff, clinic, and livelihood may opt for approaches that are quicker and easier when caring for patients. This strategy may be of low value when compared with approaches that could be taken if physicians had the time and ability to be more invested in their patients’ well-being.” Often, physicians do not know or have access to information about the costs of the diagnostics and therapeutics they prescribe. Others may be unaware of the percentage of costs that patients will assume if they undergo these procedures. “Value can’t be assessed if the costs are unknown,” Dr. Umscheid says. “Further complicating...
Safe Harbor for Docs  Who Follow Guidelines

Safe Harbor for Docs Who Follow Guidelines

Physician leaders are supporting a new proposed federal law that aims to reduce litigation against physicians, lower healthcare costs, and establish more fairness in the analyzing of malpractice claims. The new House bill, Saving Lives, Saving Costs Act, introduced by Congressmen Andy Barr (R-KY) and Ami Bera, MD, (D-CA) would create “safe harbor” – protection from liability – for physicians who follow best practice guidelines from malpractice suits. More than 75% of physicians face a malpractice claim over the course of their career—a liability climate that can drive patient care and encourage overutilization, adding billions of dollars in health costs each year. And patient outcomes don’t appear to improve as a result. If the physician being sued argues that he or she adhered to relevant, best practice guidelines, the case will be put in front of an independent medical review panel for investigation. If the panel determines that the clinician did comply to the guidelines or that the injury was not caused by failure to comply, the case will be dismissed. Personal injury lawyers are pushing back, one in particular claiming: “There is no evidence, however, that this safe harbor would actually promote patient safety. In fact, in Texas, where emergency room physicians have had immunity since 2003, patient safety has steadily decreased.” The Center for Justice and Democracy argues that clinical practice guidelines should not be used as a legal basis for determining negligence. The organization claims that there is already a general recognition that conflict of interest and specialty bias are ongoing problems in the development of clinical practice guidelines. Other concerns include the numerous, and sometimes contradictory, guidelines...
Patient-Provider Dialogue With HIV Drugs

Patient-Provider Dialogue With HIV Drugs

Research has shown that race and ethnicity may be associated with differences in how healthcare providers communicate with patients. “In HIV, a key component to outcomes is adherence to antiretroviral therapy (ART),” says Michael Barton Laws, PhD, MA. “Investigators have hypothesized that clinical communication may be a factor in how well or poorly HIV patients adhere to ART regimens.” Examining Themes In a study published in AIDS and Behavior, Dr. Laws and colleagues reviewed more than 400 routine outpatient visits by people with HIV. Three themes emerged from the analysis of patient–provider conversations, depending on patients’ race and ethnicity: 1) Speech patterns: African Americans spoke less to their providers than Caucasians or Hispanics. Hence, there was greater provider verbal dominance in their discussions. They also less frequently expressed their goals or values. Healthcare providers asked Hispanics fewer open-ended questions. 2) ART adherence: Visits with African-American and Hispanic patients included more dialogue about adherence than visits with Caucasian patients. This difference occurred regardless of how adherent patients reported being to their ART regimens or whether laboratory tests showed that HIV was under control. 3) Problem solving: The more extensive dialogue about ART adherence between patients and healthcare providers was directive rather than problem solving. “There was more discussion about ART adherence with African Americans and Hispanics,” adds Dr. Laws, “but no more discussion about strategies to improve adherence.”   Possible Interpretations Dr. Laws says that several factors may influence why healthcare providers talked more with minority patients than with Caucasians about adherence. “It’s possible that healthcare providers are trying to compensate for what they’ve seen in studies about lower adherence...
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