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At Intermountain Healthcare, an Ongoing Discussion of Unnecessary Care

March 6, 2014
by Mark Hagland
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Greg Poulsen, senior vice president and chief strategy officer, shares his perspectives

For decades a leader in internal healthcare system reform, Intermountain Healthcare has blazed trails in every area of clinical and operational performance, as well as in care management, disease management, and early electronic health record (EHR) development. What’s more, leaders at the 22-hospital, 185-clinic integrated health system based in Salt Lake City have spent decades looking at patient care delivery from the patient safety, care delivery quality, operational efficiency, and utilization standpoints.

In that context, Intermountain leaders have spent decades thinking about and analyzing patterns around physician delivery of a variety of procedures, and utilization trends, both internally and in relation to nationwide patterns and trends.

One Intermountain executive who has been instrumental in all these activities is Greg Poulsen, who has been with the Intermountain organization for 31 years, and who has been senior vice president and chief strategy officer there for 20 years.

In that context, Poulsen will be delivering the opening keynote address, “Eliminating Unnecessary Care with IT,” at the Health IT Summit in San Francisco, to be held March 25-26, and sponsored by the Institute for Health Technology Transformation (iHT2). The Institute became a part of Vendome Group, LLC, Healthcare Informatics’ parent company, in December 2013. Poulsen spoke recently with HCI Editor-in-Chief Mark Hagland about the ongoing activity taking place at Intermountain Healthcare around unnecessary care. Below are excerpts from that interview.

What is the background in terms of your organization’s work on unnecessary care?

It actually started about 20 years ago. This is something that’s been on our minds for a long time. And I think that the indications were that we became aware, as were others, of clear cases of abuse, where case was being provided that was unnecessary, for financial reasons. And you’ve seen the New York Times articles on this topic, for example; it’s really hit the headlines in the past few years, but thoughtful people have been aware of it for decades. And maybe I can take some responsibility for this—about 25 years ago, everybody in the country was putting together strategic plans for joint ventures and surgical centers, and such; and I said, I think this is a horrible idea, and a dead-wrong incentive, because it gives people the opportunity to try to be paid doubly. And we made a policy decision in our organization to prevent that here. And there were a lot of unhappy physicians back then, and many ended up creating surgical centers on their own anyway. But it led Brent James [M.D., executive director of Intermountain’s Institute for Health Care Delivery Research] and myself and others to engage in discussions about care that was clearly unnecessary. We became aware, for example, of radiation oncology centers in Texas that were providing two to three times as much radiation as called for.

Gregory Poulsen

And we came to the conclusion that these are not victimless crimes; first of all, the taxpayer or somebody is getting ripped off. But we seriously couldn’t think of an example where people weren’t put in harm’s way while getting care that was unnecessary; they were going under anesthesia or being exposed to radiation, or receiving meds, that were unnecessary. So we came to conclusion that unnecessary care can be not only problematic, but also harmful. And we were becoming more and more through our research that this was a systemic problem.

And there were incentives throughout the healthcare system until recently, for unnecessary care.

Yes, including with regard to the practice of defensive medicine. And we started out trying to avert abuse situations. And then over the next 15 years or so, Brent and I came to the conclusion that it’s probably more pernicious than that—not that unnecessary care is being regularly provided in a fraudulent or malicious way, but rather, that it’s just osmotic—it just creeps forward. And then the Dartmouth Atlas was created and published. And one of the reasons it hasn’t had as much impact as it might have, is that they’ve tended to do it in an academic way and also one at a time, in terms of back surgery or hip replacements, for example. And they’ll come out with statements such as, for example, Buffalo, New York has the highest rate of such-and-such surgery in the country. I do remember that Provo, Utah, where I am, had the highest rate of back surgeries in the country. And were neurosurgeons paying more attention to back surgery, perhaps? But it was very atomized in approach.