Accountable Prescribing

Nancy E. Morden, M.D., M.P.H., Lisa M. Schwartz, M.D., Elliott S. Fisher, M.D., M.P.H., and Steven Woloshin, M.D.
The New England Journal of Medicine, July 25, 2013

Physicians spend a lot of time treating numbers — blood pressure, cholesterol levels, glycated hemoglobin levels. Professional guidelines, pharmaceutical marketing, and public health campaigns teach physicians and patients that better numbers mean success.

The first line of defense against poor prescribing should be clinicians’ commitment to responsible, evidence-based practice. Unfortunately, clinicians frequently prescribe medications that improve numbers without necessarily improving health.

To avoid rewarding poor prescribing, we could more closely align quality measures with evidence. The table (available at link below) highlights widely used quality measures that span a spectrum in terms of encouraging accountability; we suggest revisions for those that we believe don’t adequately require prescribers to pursue evidence-based, cost-effective choices. Although some physicians may disagree with specific suggestions, our main interest is in the principle of moving beyond numerically driven quality measures to measures that match treatment goals to the best evidence and encourage use of the safest, most effective, and lowest-cost drugs or nondrug treatments.

Payers could accelerate implementation of accountable prescribing. The table provides a starting point for revising existing measures. In addition, payers could advance and facilitate less onerous measures through claims analysis. Although claims and surveys are the basis of some quality measures, much performance is assessed through Web reporting: payers provide practices with measure-specific lists of eligible patients, and physician groups or institutions review records and report performance for each patient according to definitions of the target care. This is the approach used by the Centers for Medicare and Medicaid Service (CMS) for accountable care organizations (ACOs) and by the PQRS. Because organizations such as ACOs are responsible for defined populations, payers could monitor quality through claims analysis. Prescribing quality may be particularly amenable to this approach. Performance measures based on prescriptions claims could include, for example, the population-level ratio of second-line treatments to first-line options or the ratio of brand-names to generics in drug classes in which ample generics exist. Monitoring could permit efficient determination of clinicians’ response to new drug warnings, and claims analysis could quantify long-term adherence to safe, effective drugs.

Accountable prescribing measures could also incorporate cost. Though some payers may hold providers accountable for prescription spending, CMS programs do not yet do so. CMS shared-savings calculations are currently based on inpatient and outpatient expenditures only, but that doesn’t preclude the inclusion of prescription spending in quality measures. Although prescribing decisions should be driven primarily by safety and effectiveness, cost can be an appropriate tiebreaker among drugs that are equally safe and effective. Considering costs may also discourage use of newly approved brand-name drugs that lack safety or efficacy advantages — drugs with potential shortcomings that have had less time to emerge.

As insurance coverage expands, we must ensure that greater access to prescription drugs confers better health, not harm. The need to advance performance measures as health care reform proceeds is well recognized. Ideally, we should assess outcomes valued by patients, but for reasons of feasibility, many measures focus instead on surrogate end points. To improve health, such end points must be based on strong evidence, and how you get there matters. Refining measures to incorporate best evidence and the notion of accountable prescribing could promote use of the safest and most effective drugs, better align measures with our professional responsibilities, and maximize the chance that meeting goal-driven performance measures will translate into improved population health.

In the mania surrounding the implementation of Obamacare, the hope for controlling spending and improving quality lies in assigning accountability in the delivery of health care, especially through accountable care organizations. Supposedly we should be able shift from payments based on quantity of services to payments based on accountability for quality outcomes (certainly a sketchy premise). How is that playing out?

This article from the Dartmouth Institute gives a hint of how accountability might be measured in practice, in this case through accountable prescribing. Read what they propose and then use your imagination. First you extract the required data from the patient. Then, after you get the patient out of your way, you will need to access the algorithms for prescribing. Next you can go ahead and follow the appropriate algorithm pathway on your computer. After a period of interacting with your keyboard and your mouse you will have arrived at prescription nirvana, having determined the highest quality and lowest cost drug selection for your patient.

Of course, this is only the drugs. But since the goal is to include adequate measurements to determine the full level of accountability, similar algorithms will have to be followed for other aspects of the diagnostic and therapeutic interventions. Of course, there may be some complexity with the more technical aspects of care, such as the complex algorithms of intensive care, or of surgical management, or whatever.

But establishing accountability is the goal and is what must be measured. Today’s policy wonks are leading the way. The payers, to be led by Medicare, are to determine appropriate distribution of funds based on how well the providers follow the wonks’ algorithms. And the patient? Oh yes, if she hasn’t left the room yet, you can let her know that the computer’s algorithm has prescribed metformin as the next step in management of her diabetes. Score 100. One step closer to collecting your reward from the Medicare shared savings program.

And, oh, the patient. She says she wasn’t there for management of her diabetes? She’s there because her husband can’t give up sexting, and she’s profoundly depressed as a result? Gee, is there an algorithm for that? And doesn’t this mess things up by requiring a greater quantity of care? And would there be a way of lowering the cost for that care? In fact, not only does the situational depression need to be managed, but doesn’t something need to be done about the husband’s sexting paraphilia? Never mind. There is no accountability algorithm for that yet anyway. Besides this encounter has already received a perfect score for the shared savings program. Next patient.

Message to accountability policy wonks: The health care system doesn’t exist merely to assign and measure accountability of the health care professionals and institutions, which in itself is a time consuming and administratively burdensome endeavor. It exists to take care of patients. Can’t we get back to that?