DVT project finds budget balance at the intersection of cost, quality
Getting the changes worked into the system wasn’t overly difficult, said Dr. Frederick Finelli, vice president of medical affairs at MedStar Montgomery Medical Center in Olney, Md.
"The physicians were mixed about how they felt about it," he said in an interview. "Some liked one heparin over another, for instance. We had to spend some time on getting a consensus, but we did work it through."
Implementing the medication change wasn’t hard either. The hospital system reorganized its computerized physician order entry system to offer unfractionated heparin as the default choice. "We made it easy to do the right thing and hard to do the wrong thing," Dr. Finelli said. "The algorithm for determining the right dosage is right on the order screen. The heparin is prioritized with unfractionated at the top of the list."
But a physician’s clinical judgment can still override the system, he added. "If you order the low-molecular-weight heparin, the instructions do come up saying that it’s recommended only for patients with cardiac surgery, trauma, or spinal cord injury. So you can still order it. If a physician understands what MedStar wants to do, but disagrees in a particular case, the low molecular weight is available. We think it’s a system that works."
Changes in the use of SCDs went into effect at the beginning of 2013, Dr. Finelli said. Physicians had to work to come to consensus on this point as well – and it was not as easily or thoroughly accomplished.
"There were some surgeons who really liked using them and not using an anticoagulant, so getting buy-in from them was not possible," said Dr. Finelli. This was especially true for those who dealt with cases in which bleeding would cause a great deal of harm, such as spine surgeries.
"These surgeons do continue to use the SCDs vs. heparin. So they do maintain control. We leave some leeway for it."
The next ‘best’ thing
The whole strategy gets a continual tune-up, he added. "We have an established committee of doctors, nurse practitioners, and information technology people who meet every 2 weeks to keep the process up to date."
In fact, flexibility is one of the best things about a value-based systems analysis, Dr. Kirkpatrick said. "We’re always looking for the new ‘best practice.’ What’s a best practice now could be obsolete in 2 years. We will keep updating what we do."
After just 8 months, some of that change may already be upon the program, Dr. Finelli said. In 2010 – 3 years after the Surgical Advisory Group began looking at the issue – low-molecular-weight heparin became available in a generic formula, narrowing the 10-fold cost differential.
"If the price drops low enough, we may want to switch that entire practice around. It’s much more attractive because it’s given once a day, there’s less nursing administration time, and greater patient satisfaction."
For now, though, it’s tough to ignore the total cost savings both practice changes will generate, said Dr. Kirkpatrick. "The reason it’s so significant is that those savings go right to the bottom line. A system like MedStar is very efficient, but the profit margins are still small – 1.5%-2%. There are not many $4 billion/year operations that can survive on a margin like that."
There’s always a cost – even to saving – and that, in the end, determines a project’s worth, said Dr. Stephen Evans, executive vice president of medical affairs and chief medical officer of MedStar Health.
"There are thresholds of cost usefulness. If you have a $40,000 savings, but it’s a laborious process to get there, that’s one thing. But a $4 million savings that’s relatively simple is obvious."
In this case, with the money going directly into the operational budget, the entire system benefits. "This is anew CAT scanner, or 10 new nurses. Part of the incentive for people to get costs under control is so they can look to reinvestment in the business. If everyone understands the goal of reinvestment, it’s a much greater incentive for everyone to participate."
Dr. Kirkpatrick is executive director of the Surgical Advisory Group. Dr. Evans and Dr. Finelli had no financial disclosures, other than their MedStar employment.
*Correction, 4/22/13: The photo caption in an earlier version of this story incorrectly identified Dr. Frederick Finelli.
