A Changing Healthcare System
It is projected that by the year 2020, cumulative medical knowledge will be doubling every 73 days. At that rate, it can be argued that no professional anywhere in the healthcare system would be able to keep up. Even experts in niche fields would have little to no capacity for learning much outside of their subspecialty.
To address this challenge, Dr. Eric Gratias, SVP & EviCore co-CMO, is interested in finding ways to distribute the evidence-based guidelines developed by EviCore in a format that the medical community can trust, to help them make faster and better decisions.
Cost of Care and Changing Mindsets
As we continue to progress in our medical knowledge and treatment ability, it is important that physicians proactively consider the challenge of out-of-pocket costs; otherwise patients may end up foregoing necessary treatments or prescriptions. If patients can't afford a prescription, they may not share that information until their next appointment (or not at all) because they are embarrassed or don't want to be perceived as a burden. Or worse, they may spend money on a prescription that was needed to pay for gas, food, or electricity. During ongoing treatment for cancer or other chronic illness, a patient's income source can quickly dry up. All of this, says Dr. Gratias, can lead to “financial toxicity."
Another of the key principles in the Hippocratic Oath is to “do no harm." Being completely blind to cost has become a potentially harmful mindset. “We need to be aware that in today’s complex medical world you may actually be causing harm to a patient by completely ignoring the cost of care," he says.
The cost trajectory that we're on is not sustainable," Dr. Gratias warns. The national budget is increasingly weighted towards healthcare spending and if current trends continue, then eventually even basic infrastructural services will begin to suffer. Current projections from CMS suggest that within the next 10 years or so, a third of the GDP will be spent on healthcare, and the economy may start to fail. “Prior authorization," he says, “while challenging at times, currently plays an important role in cost containment that is slowing our spending trend."
Peer-to-Peer Conversations—Not a Bad Thing
As the healthcare system continues to grow and change, Dr. Gratias encourages EviCore employees to consider “how we take the principle of accountability and evolve from the traditional somewhat adversarial role to a more collaborative one." He suggests that meaningful conversations, resources, and education will all play a crucial role. The first place for ensuring this collaborative spirit is in the peer-to-peer experience.
Dr. Gratias shared that he's personally experienced many collaborative conversations during peer-to-peers. In one example, he received a call from a physician who asked where the information for his decisions came from. Dr. Gratias pointed him to the guidelines freely available on EviCore’s website. Following those guidelines, he says, will generally result in an approval. During the conversation, the physician commented that he was surprised by the depth and breadth of the guidelines, and expressed appreciation for the knowledge that this information was transparent and available. The physician then asked him what would happen if he believed something to be incorrect in the guidelines. Dr. Gratias replied, “If you see something you think is incorrect, then please send that feedback supported by references. If a change is appropriate, then we'll definitely make it." In another situation, a physician kept a scheduled peer-to-peer call on the calendar just to tell him that she had reviewed the guidelines, and our guidelines had helped her understand a blind spot that had developed in her own knowledge over time.
In the end, it's about remaining flexible, embracing change, and facilitating open and collaborative conversations around the quality and cost of care that center on each patient’s needs. It’s easy to forget that healthcare is a team sport, not an individual one. After all, we're all in the business of helping people get well and stay well.