A guest blog from Lu Crowder, AMR’s Director of Clinical Quality
In a conversation with a work associate about professional challenges and inspiring business opportunities, my thoughts quickly turned to Evidence Based Medicine (EBM) and the thread it has woven throughout my career and practice of nursing. Today, as I oversee the clinical quality of client services at Advanced Medical Reviews (AMR), EBM is central to the work we do every day. Our clients expect us to make recommendations that help ensure their members receive the right care in the right setting at the right time. Interestingly, those words were also central to the conceptual framework in the early days of EBM, some 40 plus years ago in this country, and have been a lasting premise of quality healthcare since.
The EBM Movement
I first had the privilege to become involved in the evolution of EBM as a part of my work in the employee benefits division of a Fortune 100 corporation in the early 80’s. Prior to that, during my scientific training and early clinical practice, I generally assumed that health care decision making was more scientifically based, but those early EBM sessions revealed that was not always the case. Despite the fact that medicine in the US was practiced by highly educated physicians with extensive practical internship and residency education, medical practices were not always grounded in proven scientific evidence and were often subject to wide variations. Through my work with leaders of that movement, it became clear that, prior to this focus on EBM, providers practiced health care differently for a variety of reasons: variations in training, inherited practices local to smaller communities, proximity to teaching hospitals, and more. Compared to today, there was a lack of controlled scientific trials that provided evidence of the benefits and risks of specific treatments. These gaps in evidence sometimes led to differences in clinical reasoning and undesirable patient outcomes.
To remedy the variation in care and treatment, over the next four decades, providers of health care along with other scientists, scholars, statisticians, payers, regulators and corporate leaders convened regularly to share research and communicate findings. Through their frequent meetings, conferences and writings, these leaders began to drive improvements in health care delivery through scientific analysis. These forums were not only useful to physicians in their clinical practice, they also started to influence standards upheld by payers. Insurers, self-funded health benefit plans and other health care payers started basing their payments on whether the delivery of care met evidence-based standards. EBM research and education over the last four decades has paved the way for health care based on scientific methods and has led to improved outcomes.
Shifting Health Care Perceptions
Large US-based companies such as GE, AT&T, IBM and Federal Express, were early adopters of EBM practices due to their goodwill and investments in their employees. At the same time, clinical case management was evolving and often paralleled EBM developments. In my company, we developed and implemented a clinical case management process led by a team of nurses who worked directly with employees who needed and requested help with complex health problems. The case management RNs helped employees understand their diagnosis, the treatments they were going through, or even to prepare questions to ask their doctor. Rather than managing health care based on a strict formula of do’s and don’ts, we helped our employees manage their own health care through better understanding and inquiry. By creating the opportunity for patients (employees) to reach out to nurses with questions about complex health conditions, we helped them manage how their healthcare was being delivered and received and to take an active role in determining if the care was appropriate and necessary for them.
Effective case management is individualized and requires an investment of time on the part of the case manager, the employee/patient and often their family. Cost savings can be realized along with better patient outcomes and a more comfortable environment of care.
For instance, when a pregnant woman in her third trimester was determined to be high risk and the initial plan of treatment was inpatient hospital care until delivery - up to two months - we were able to replace hospital care with company reimbursed short-term housing adjacent to the hospital. The patient was able to be close enough to her care team in an emergency and still be with her family in a homelike environment. It’s a situation where “everybody wins” as a result of non-traditional thinking, and the company was open-minded enough to support an alternative option.
The Road to Better Outcomes
Since the 1990s, we've been perfecting these processes. Large insurance carriers and employers with self-funded health benefits take EBM guidelines very seriously. The guideline criteria are frequently updated based on scientific data, case studies and changes in the medical world and are the basis for the majority of medical decisions. In recent years, the end user, being the patient, is becoming more and more important.
At AMR, most of our clients – group health plans, third party claims administrators (TPAs), Managed Care Organizations (MCOs) and other payers - encourage a comprehensive, patient-specific, approach to administering guidelines. Many of our reviews include a question that is based strictly on the scientific criteria and then a second question that allows for consideration of unique, member specific reasons that would result in a recommendation of medically appropriate for a service that might not be approved based on strict criteria alone. As such, we are seeing a trend of evidence based medical reviews that incorporate a “whole person” reality inclusive of social determinants of health that are becoming more and more a part of understanding the care a patient needs.
The Medical Directors of AMR clients review their guidelines and EBM standards at least annually and many as frequently as quarterly. Our physician reviewers, usually physicians in active practice who review cases related to their own medical specialty area, bring their expertise and patient care standards to the case review process. They are also frequently invited to participate in the periodic review of client guidelines based on their knowledge of relevant standards of care, new FDA approvals or recent developments in scientific case studies.
It really pleases me to work with AMR clients, their Medical Directors and our physician reviewers and to have the opportunity to witness in action the health care service determinations based on evidence based standards. I leave these interactions feeling assured that we collectively truly care about making informed determinations that ensure patients receive appropriate and medically necessary care. We are meeting the goal of right care, right setting and right time. It’s no coincidence that AMR’s belief statement is we believe every patient should receive quality healthcare.
The Future of Health Care and EBM
One of the heartening things about how healthcare is delivered today is that physicians, nurse practitioners, nurses, home health aides or other personal care attendants are, more than ever before, a cohesive group with a goal of providing the best possible care for the patient with the least amount of disruption and cost. The evolutionary process can seem slow, but hindsight allows us to see how much we’ve grown. As is the case no matter the industry, we just all have to continue talking and listening to each other. Human interoperability, as it were, still remains one of the most effective tools for growth and progress.
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