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Intermountain’s Ongoing Discussion of Unnecessary Care: Is Your Organization Ready?

March 8, 2014
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Greg Poulsen’s leadership in discussing unnecessary care provides insights and strategies

It was great speaking earlier this week with Greg Poulsen, senior vice president and chief strategy officer at the Salt Lake City-based Intermountain Healthcare. Poulsen, who has spent over 30 years at the 22-hospital, 185-clinic integrated health system, 20 of those years in his current position, has been leading important, sometimes uncomfortable, discussions about the topic of unnecessary care for years.

As Poulsen, who will deliver the opening keynote address, entitled “Eliminating Unnecessary Care with IT,” at the Health IT Summit in San Francisco, sponsored by our partner organization the Institute for Health Technology Transformation (iHT2), told me, he and his colleagues at the always-pioneering Intermountain have been thinking about, talking about, and trying to find solutions to, this problem for over twenty years now, so I look forward to hearing what I’m certain will be a very thoughtful keynote address in San Francisco.

What’s particularly interesting is to hear from Poulsen about how the long-term initiative around unnecessary care first emerged.  “About 25 years ago, everybody in the country was putting together strategic plans for joint ventures and surgical centers, and such,” he told me. “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.”

Greg Poulsen

Equally important is how the Intermountain folks have gone about doing something about the unnecessary-care problem. First, about seven years ago, they approached CMS (the federal Centers for Medicare and Medicaid Services), and asked to access the entire nationwide MedPar (discharge) database, rather an audacious request to begin with; yet that is also the database that the Dartmouth Atlas people had been using for years to develop their reports, which have for years shown incredibly wide variations in utilization and service delivery across healthcare. Then they combined the MedPar data with commercial insurance data, data from within Utah, and of course, their own vast organization’s data, and began to drill down into levels of granularity that provided often-surprising insights into variations in care delivery and utilization patterns.

Poulsen’s story about looking at the widely varying cardiac stent rates among physicians in the Ogden, Provo, and Salt Lake City subregions within the Wasatch Front region was particularly illuminating. As it turns out, cardiac stent rates in one of those subregions (he wouldn’t specify which one) were completely out of alignment with those same rates in the other two regions. So what did Poulsen and his colleagues do? They sat down with the physicians in that region, showed them the data, discussed the data with them—and that was it. Yet within a year, the cardiac stent rate in that area decreased until it had matched the rates in the other two areas. Why? Obviously, because the doctors simply talked with each other about what they were doing, and the doctors in the outlier region realized that they could easily shift some of their patients to watchful waiting over the previous norm of immediate surgical intervention.

It is stories like that that speak to the power of the careful, thoughtful, strategic leveraging of data in a changing physician practice environment. Now, obviously, until recently, in an overwhelmingly fee-for-service-dominated payment environment, there would have been no point in that type of exercise. But as we all know, the world is changing very rapidly now in healthcare, and as the leaders of patient care organizations take on federal reform-driven mandates like the reduction of avoidable readmissions, and join together to create bundled-payment contracts, accountable care organizations, patient-centered medical homes, and population health management initiatives, strategies like those pursued by Greg Poulsen and his colleagues at Intermountain will become more and more important—and common.

The subject of “unnecessary” care has always been a heavily freighted one in healthcare, as it immediately provokes defensiveness in many physicians, alarm among CFOs still operating in the fee-for-service environment, and general confusion and anxiety. But more and more, as we move into the new healthcare—a U.S. healthcare system driven by public and private payer and purchaser mandates for patient safety, care quality, efficiency, cost-effectiveness, accountability, and transparency—the “unnecessary” discussion will become a necessary, even essential one, going forward. And what better way to pursue the discussion through thoughtful, strategic, open-ended data-sharing?