Soraya Ghebleh

Unwarranted Variation in Healthcare

Unwarranted variation refers to differences in the practice of medicine that cannot be explained by illness, medical need, or evidence-based medicine. The three areas of care that cause unwarranted variation are effective care, preference-sensitive care, and supply-sensitive care. Effective care is defined as interventions for which benefits far outweigh the risks and the right rate of treatment is for every patient that meets clinical guidelines to be in need. Preference-sensitive care is when given two equally viable treatment options; the patient must make a decision about their treatment and the correct rate of use should depend on patient choice. Supply-sensitive care refers to capacity determining the amount of treatment a patient receives rather than whether the treatment is necessary for a better patient outcome. Regions with higher use, however, do not demonstrate better outcomes overall. Unwarranted variation is one of the drivers of excessive waste in the healthcare system and contributes to wide differences in the quality of care and disparities in health outcomes across clinical settings. The problems associated with unwarranted variation have been expounded on but the next step is proposing solutions to create a better, more efficient healthcare system that is consistent regardless of geographical location and setting.

One potential remedy that can help reduce unwarranted variation is widespread introduction of shared-decision making (SDM). Shared-decision making addresses problems associated with preference sensitive care. When a patient is given two treatment options, for example having a hip replacement compared to managing pain without surgery, they must make a decision. In many cases patient decisions are influenced by professional opinion and trust in physician choices. The lifestyle of the patient and what is important to the patient is not always taken into consideration when making these preference-sensitive decisions about healthcare choices. SDM can address this by providing the means for patients to truly understand the implications of decisions about healthcare by increasing patient education, involving the patient in the decision, and helping patients ask the right questions about how to proceed with their care. Potential barriers to implementation are resource-constraints for proper implementation and having physician buy-in to the notion that patients should have decisions regarding their care that they may not agree with.

Another strategy for reducing unwarranted variation involves re-aligning financial incentives with value-based care. Under the current fee-for-service model, physicians are rewarded for providing volume-based care. This is one of the drivers

of supply-sensitive care. Many clinical settings have a high capacity to deliver care and as long as providers are reimbursed for quantity rather than quality, they will continue to deliver services that often go beyond the scope of necessary care. Introducing new payment models like accountable care organizations and bundled payments have the potential to reduce utilization just because supply is available and encourage providing care that is based on actual need. There are many challenges in introducing new payment models to the current healthcare system. Provider behavior is difficult to change and the prevailing attitude that “more is better” will require a paradigm shift in how providers and often patients define quality care. Re-organization of healthcare systems is also difficult and whenever changes are introduced, criticism and backlash is expected.

A third way of reducing unwarranted variation is improving health outcomes research and disseminating information accordingly to providers. Many providers are unaware that their outcomes differ from other providers, even within their own clinical institutions. The development of strong, evidence-based outcomes data is essential in determining what is effective and necessary care. This can help address supply-sensitive care. If evidence exists that demonstrates to providers that how they provide care can be improved on in a systematic fashion, this can be an important tool in creating a more consistent healthcare system. National registries can assist in assessing the outcomes in different clinical institutions. Simply sharing data to improve the quality of care delivered and provide a basis in evidence can help providers be aware that there are differences and begin to understand why certain providers or clinical settings may produce better outcomes as compared to other providers or clinical settings. This may be one of the more difficult areas to address because physicians value their clinical autonomy and do not want to be held comparable to their colleagues around the nation. Many institutions do not necessarily want to see how they compare to other institutions in terms of both resource utilization and expenditure. These three potential remedies provide opportunity to reduce unwarranted variation, especially if implemented simultaneously.