Timing: The third element of value-based care

May 16th, 2019

Health care value is generally defined as health care benefit for each dollar spent. When we think of initiatives to improve health care value, we think of policies that reduce the volume of unnecessary tests, drugs, and procedures, or policies that lower prices for health care services. But what if there was another way to improve the bang for each health care buck?

In a new commentary piece in JAMA Internal Medicine, Dr. Andrew Ibrahim and Dr. Sameer Saini at the University of Michigan explain how conducting some related health care procedures at the same time can save money and reduce risk. For example, examinations of the gastrointestinal tract with an endoscopy (to view the stomach and small intestine) or colonoscopy (to view the large intestine) are often done at different visits, but both procedures can be done at the same visit. If a patient will require both types of endoscopies, doing both on the same day means the patient only needs to be sedated once, their risk of infection is reduced, they only need to take one day off work instead of two, they only need to recover once, and they only need to pay once for facility fees. 

This seems like a win-win — patients have less risk and hassle at lower cost. And yet, nearly half of physician’s office that performed endoscopies and colonoscopies on patients within the same 90-day period did them on different days, according to a recent study by researchers at John’s Hopkins University. Why not perform more concurrent procedures? For some patients, it may not be safe to perform both procedures in the same visit. But it’s likely that reimbursement plays a larger role.

Doing endoscopies and colonoscopies on different days allows clinicians to bill more, because they can include clinician and facility fees for each day. Even accounting for patient characteristics, the study by Johns Hopkins showed extreme variation between physicians in whether they performed procedures on the same day or different days. The average rate of different day procedures for doctors in physician’s offices was 47.4 percent, but more than a quarter of these physicians performed 90 percent or more of endoscopies and colonoscopies on different days, which is clearly not clinically necessary.

“The message is clear: unwarranted variation exists for a pair of the most common and costly outpatient procedures,” write Ibrahim and Saini.

Endoscopies aren’t the only outpatient procedures that can be performed concurrently. Ibrahim and Saini point out that there are related procedures in cardiology and dermatology that can be done on the same day to reduce patient risk, hassle, and cost (echocardiography and stress echocardiography is one example).

Hopefully more research and value-based payment models will increase incentives for doctors to think more about timing when scheduling related outpatient procedures. 

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