Evidence-Based Surgery - (Chapter 3 Stakeholder Perspectives)

CHAPTER 3
Stakeholder Perspectives
O
John D. Hundt, MHS, Charles Reuland, MHS, and Keith D. Lillemoe, MD
Understanding the perspective from which research information is presented can shed light
onto the self-interests, ethical obligations, and economic incentives of those conducting the
research. Therefore, one must understand who the stakeholders are in the research and what
their perspectives might be. Generally, the stakeholders are thought to be patients; providers,
including physicians and hospitals; payers, including managed care organizations, employers
and the government; the industrial sectors that support health care delivery, for example,
medical supply and device manufacturers; government policymakers, and private nonprofit
policy concerns such as research foundations.
The perspectives of these stakeholders range from those of the individual patient to those
of society at large. For example, while clinical research is generally from the perspective of the
patient, most health policy research attempts to relate to a societal perspective. While such
policy research supports resource allocation decisions at the societal level, decisions about
one’s personal health care are not made at the societal level. Further, conclusions drawn from
a societal perspective may not directly influence the delivery of health care since each stake-
holder in the health care delivery system has varying degrees of personal and financial risk and
responsibility and has different incentives. Ultimately, the authority to organize, coordinate,
and improve services rests with providers and payers whereas a patient must decide whether
to consent to services offered by a physician.
Outcomes research generally focuses on three dimensions of outcomes: clinical, eco-
nomic, and patient-reported.1 Stakeholder perspective may determine which of these dimen-
sions are considered in the research and how they are measured. Much evidence-based
medicine is centered around the impact of interventions on patients (eg, biologic measures
such as survival; disease or treatment complications; physiologic, anatomic, or laboratory
Copyright © 2000. B. C. Decker Incorporated. All rights reserved.
abnormalities; and signs and symptoms). Much of the evidence-based surgery literature
describes clinical outcomes, that is, morbidity and mortality. However, purchasers define out-
comes principally in economic terms. Measures important to a patient extend beyond clinical
and economic outcomes to aspects of physical and social well-being and functional status.
(These dimensions of outcome—clinical, patient-reported, and economic—are covered exten-
sively in later chapters.) Cost considerations are of paramount importance in health care today.
The emergence of population-based research coupled with new information technology
has created a new literature about outcomes research. Quality, access, and cost are the three
traditional parameters of interest to the various stakeholders and must be considered with
respect to the role of surgery across the continuum of care including
• early detection and screening,
• diagnostic evaluation,
• primary and adjuvant therapy,
• surveillance and follow-up,
• treatment of recurrence,
• palliative care, and
• end-of-life care.
Gordon, Toby, and John L. Cameron. Evidence-Based Surgery, B. C. Decker Incorporated, 2000. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/uta-ebooks/detail.action?docID=3386878.
Created from uta-ebooks on 2017-07-21 08:21:35.
40 Evidence-Based Surgery
Significant trends in surgical care technology, including shifts to minimally invasive care and
interdisciplinary care, are important considerations along the continuum.
Considerations that might be important to different participants in the health care sys-
tem are as follows:
• Patients: out-of-pocket costs, lost functionality
• Providers: reimbursement
• Payers: expenses incurred
• Employers: lost productivity, cost of care over time
• Government policymakers: societal costs, use of scarce resources
The health care delivery and financing system in the United States is decentralized and
fragmented, and health care information at the patient level across the continuum of care may
be scarce. Outcomes analysis may look narrowly at a specific procedure for a specific condi-
tion, for example, colectomy for malignant neoplasm of the colon. Outcomes can be analyzed
across a surgical specialty, for example, adjusted mortality rates for open heart surgery. Broad
measures across patient populations and multiple disciplines may also be used, for example,
surgical infection rates for all types of procedures. For a patient or referring physician making
a decision about whether to have or perform a specific surgery, broad measures may be less
useful. For a payer making a decision about which health systems to include in a health main-
tenance organization (HMO) network, broad measures may be useful. Whether an analysis is
intended to aid in choosing among care options for one specific patient or to help policy-
makers decide on the adoption of a new technology is an issue of perspective.
SPECIFIC PERSPECTIVES
Patients
Patients are most interested in information that will help them make a decision about treat-
ment they are seeking or that has been recommended. Risk and behavioral factors for a given
patient may not be identified in the information on hand. For example, the preferred treat-
ment in the literature may not be recommended to a patient unable to comply with complex
postoperative treatment. Patients may require additional help in understanding contraindi-
cations to given treatment options. (A separate chapter addresses the topic of consumer
health information.)
Patients get information about the value of surgical procedures from a variety of sources,
including family and friends, physicians, and the media (as described in a later chapter on
consumer health information). Information in the paid media (eg, advertisements) may be
aimed at increasing the use of surgical services. For example, in an eight-page supplement to
the February 5, 1999, edition of the national newspaper USA Today, readers are informed that
“recent studies suggest total joint replacement has an increase in the quality of life, relative to
cost, to a greater extent than almost any other invention.” This supplement was sponsored by
the American Association of Hip and Knee Surgeons, with financial support from manufac-
turers of orthopedic devices and supplies. Thus, evidence-based surgery research can signifi-
cantly influence the market positions of companies in the medical supply and service sector.
Physicians
A physician’s primary obligation is to look out for the welfare of the patient. Historically, this
has meant that each patient’s care should be personalized with a treatment plan based on indi-
vidual patient needs, preferences, and risk factors.
Primary issues for physicians with respect to evidence-based surgery relate to planning
the most appropriate care for their patients, either as the direct care provider or as the refer-
ring physician. Primary care doctors and specialists must also serve as advocates for their
patients with managed care organizations.
Stakeholder Perspectives 41
An increase in the prevalence of risk-based payment and employment models for physi-
cians has had an impact on the perspective of physicians. For example, a surgeon or group of
surgeons at financial risk for the cost of services provided to a group of patients has financial
incentives to take a more conservative approach to treatment. Again, research on the cost-
effectiveness of care, while of interest to all responsible providers of care, may be of even
greater interest to those whose economic stake is at risk.
Hospitals
Like other components of the health care system, hospitals are confronted with a complex
environment, and this complexity has implications for evidence-based surgery and outcomes
research.
Most hospitals in the United States are staffed by voluntary physicians who are not
employees of the hospitals. Hospitals are charged with credentialing their medical staffs and
documenting that physicians meet the minimum qualifications to perform procedures. While
there is a significant amount of variation in practice patterns for treating similar conditions
(eg, lumpectomy vs mastectomy for breast cancer), the ability of a hospital to influence the
performance of its surgeons is limited. However, hospitals are increasingly using outcomes
studies to identify variation among physicians and to pursue the best practices. Hospitals and
other credentialing organizations use benchmarks to determine whether a physician is quali-
fied to perform a procedure. Privileges for certain procedures may require that providers have
previously completed a certain number of such procedures. Specialty certifications also may
have such requirements. This is consistent with the literature, which shows a link between vol-
ume and outcomes.
Currently, there are no regulatory requirements for evidence-based surgery unless some
aspect of the procedure falls under Food and Drug Administration (FDA) regulations for new
devices. The Joint Committee on the Accreditation of Healthcare Organizations (JCAHO)
does require an extensive performance improvement process, but the rigor required would not
likely meet the requirements of peer-reviewed publications.
Payers
The US health care system is best described as a pluralistic system in terms of its various
sources of payment for health care services. As of the end of 1997, 46.4 percent of national
health expenditures for US citizens were paid by a government-funded insurance program,
32.9 percent were covered by a private insurance or self-funded employer source, and the
remainder was paid directly by individuals.2 While the United States is extensively supplied
with physicians and hospitals and while the United States spends 13.9 percent3 of its gross
national product on health care, approximately 17 percent4 of the adult population lacks
insurance coverage, and there is wide variability in the quality of care available. Yet, economic
concerns over health expenditures (rather than concerns about universal access) dominate
policy debates. Managed care is the predominant organizing and financing mechanism for
health care and has had a dramatic impact on the way services are delivered.
The growth of “managed care” in the 1980s and 1990s has resulted in a variety of differ-
ent products that incentivize selection only of those providers participating in the patient’s
insurance plan. These products, including HMOs, point-of-service (POS) products, preferred
provider organizations (PPOs), and open access products, are now a significant portion of the
governmental and private payer sectors and are referred to as “network products” because
they rely on prospectively defined networks of physicians and providers. Table 3–1 shows the
size of each major payer sector and the penetration of network products into each major
payer sector.
Clearly, there are many products in which network development is a critical function and
in which decisions regarding a limited network of providers are made. Because cost, quality,
Table 3–1 Health Care Payers and Stakeholders
Health Care Funding Scenario Payer Insurer Network-Defining Entity
Self-funded employer using a TPA Employer Employer MCO
Employer purchasing an indemnity Employer Insurance Insurance company

insurance product company
Employer purchasing an insured Employer MCO MCO

managed care product (HMO,
POS, PPO) from an MCO
Medicare (traditional) Federal government Federal Medicare program

government
Medicare (HMO) Federal government MCO MCO
Medicaid (traditional) State and federal State and State Medicaid program
government federal
government
Medicaid (HMO) State and federal MCO MCO

government
HMO = health maintenance organization; MCO = managed care organization; POS = point of service;
PPO = preferred provider organization; TPA = third-party administrator.
and geographic access are all important in the decision to include providers in a network, it is
useful to describe the perspectives of the various participants. Most commonly, these partici-
pants include the payer (the actual entity that funds the health care services via payments to
the insurer), the insurer (the entity that assumes risk for costs above or below expected costs),
and the network development entity that defines the network of physicians and hospitals to
be used and contracts with the insurer for health care delivery. There are many configurations
for payers, insurers, and network developers. Table 3–1 provides examples of the most preva-
lent funding scenarios and indicates the payer, the insurer, and the network development
entity in each scenario. The purpose of this chart is to display the many variants in the
decision-making process regarding care delivery options. Those managed care organizations
(MCOs) that are responsible for network development set criteria for inclusion in their net-
works, including cost, access, and quality. Moreover, some MCOs further limit their networks
for selected services in “centers of excellence” (COE) networks. These networks identify ser-
vices believed to be more effectively provided at high-volume centers with demonstrated out-
comes. Services frequently identified for COE consideration include organ and bone marrow
transplantations and cardiovascular procedures. It is in these MCOs that the value of
evidence-based surgery may have the highest potential.
The most recent trends in managed care have shown that individuals and employers are
favoring plans that offer a higher level of choice of providers. The ability of a plan to direct
enrollees to the highest-quality provider as determined by outcomes analysis may be limited
by growth in these types of network product arrangements because enrollees may choose
providers by other criteria. Rather than mandating referral to the highest-quality provider,
plans may influence selection by publicizing superior outcomes with selected providers while
still allowing choice.
To sell network insurance products or to “rent” networks to third-party administrators
(TPAs) or self-insured employers, MCOs that perform network development must consider
cost, access, and quality. For those products for which the MCO is also the insurer, there may
be a greater willingness to limit networks to smaller numbers of providers. The quality indi-
cators most frequently used by such MCOs include licensure and board eligibility or certifi-
cation. Nonetheless, these organizations may also be interested in evidence-based surgery,
particularly to the extent to which costs are either neutral or reduced.
For those MCOs that predominantly do not assume insurance risk (PPOs), access and
cost are generally more relevant considerations. The National Committee for Quality
Assurance (NCQA) is a private, nonprofit organization dedicated to assessing and reporting
on the quality of managed care plans. To compare managed care plans, the NCQA maintains
the Health Plan Employer Data and Information Set (HEDIS), which is a set of standardized
performance measures that enable health plan information to be reliably compared. To a large
degree, these measures focus on prevention and screening. The only explicitly surgical mea-
sures included in the 1999 HEDIS are the rate of cesarean section and the rate of vaginal birth
after cesarean section.
While there are no uniform criteria for determining adequacy of physicians or hospitals,
the criteria for selection generally include location of practice, willingness to accept a given
reimbursement level, and certain minimum quality measures (eg, training and academic cre-
dentials and/or board certification). And in these areas, there is a growing level of standard-
ization, as organizations such as the NCQA become recognized bodies of accreditation for
managed care plans. It is only in recent years, however, that the use of demonstrated outcomes
has been a key determinant in the selection of some network providers. Indeed, the vast
majority of network development is still performed without the use of demonstrated out-
comes. Nonetheless, as outcomes data become more readily accessible, differentiating
providers on the basis of quality becomes a viable method of network development.
In many respects, the selection of network providers for various products has been criti-
cal to the success of managed care products.
Employers
Employers are nearly always payers for their employees regardless of whether they purchase
insured products or self-insure. In this regard, employer perspective may be similar to payer
perspective. However, employers have several other key concerns that must be addressed.
These include the impacts on workforce productivity and employee satisfaction with health
insurance benefits.
Those employers that purchase insured products may examine accessibility of the
providers in a network product to the employees but probably do not examine the cost of the
individual providers. Rather, their cost analysis will be based on the premiums they are likely
to pay. Those employers that self-insure may examine the accessibility and cost of a PPO prod-
uct, and their cost analysis will be based on the costs of the individual providers. To the extent
to which there are providers in the vicinity of the employees that are widely believed to be
quality providers, it is desirable for the employer to offer its employees health care options that
include those providers.
From the employer’s perspective, consideration of the quality of providers is likely to
depend on whether the employer is purchasing insured products or is self-insured.
Employers that purchase insured products may be less likely to consider quality indicators of
individual providers and more likely to look for NCQA accreditation as a proxy for quality.
The value of evidence-based surgery to these employers is likely to be limited until quality
measures of outcomes rather than process of care are reliably available. Employers that self-
insure may be more likely to participate in the network development process (and may actu-
ally perform it themselves). To these employers, evidence-based surgery has a potentially high
value, especially given the inherent employer incentives to maintain and promote the health
of its employees.
Government Agencies
State and federal governments have important dual roles in health care. They provide the reg-
ulatory oversight for the entire health care industry, and they are the largest payers of health
care services. Nationally, Medicaid, Medicare and other governmental spending for health care
accounts for approximately 50 percent of total spending.
As part of their roles as regulators, governmental organizations have undertaken the dis-
semination of outcomes information to improve decision making in health care. A frequently
described problem in health care decision making has been the absence of information avail-
able for patients to use in decision making. Several programs have been implemented to
improve the amount of information available. Although this information is often targeted to
patients, it probably has the largest impact on providers (for competitive reasons).
One of the earlier projects in this area included the efforts of the Pennsylvania Health
Care Cost Containment Council, which published hospital and surgeon-specific data for
coronary artery bypass graft surgery. One of the stated goals of this project was to provide pur-
chasers with information they could use to obtain greater value for their health care dollars
when it comes to making health care purchasing decisions.5 Another goal was to provide
hospitals and surgeons with information that could be used to benchmark their performance
against others. The outcomes reported included risk-adjusted in-hospital mortality rates, risk-
adjusted postsurgical lengths of stay, and average hospital charges.
More recently, efforts have been launched to develop “report cards” to help consumers
make decisions. Initial reporting specifically for surgery has been limited, with the rates of
cesarean section versus vaginal delivery being the most commonly reported.
The political process can have an impact on perceptions about evidence-based surgery.
For example, even though there has been research on the effectiveness of outpatient mastec-
tomies, several state legislatures have passed legislation requiring inpatient stays as an option.
Other Organizations
There are examples of the use of measured outcomes in surgical procedures for network def-
inition purposes. Perhaps the best example is in organ transplantation, where there have been
uniform standards for reporting outcomes for many years. The United Network for Organ
Sharing (UNOS) requires all transplantation centers to provide certain data elements to a cen-
tral repository and uses those data to calculate both expected and actual graft and patient sur-
vival rates. The expected outcomes are adjusted for various risk factors, including age, sex,
race, and diagnosis.
CONCLUSION
Regardless of perspective, a successful outcomes measurement system can be described as6
• documenting changes in clinical condition as a result of medical intervention;
• collecting data in a common format;
• maintaining data collected from multiple clinical sites in a single site to facilitate com-
parison of outcomes;
• incorporating standardized and validated methods of accounting for a health care
organization’s effect on health and quality;
• enabling physicians to assess and select medical treatments on the basis of the actual
results and cost of a treatment, to enable accurate predication of resources needed for
care;
• providing data to establish standards or guidelines for treatment;
• providing patients with specific facts to help them make medical decisions, including
facts concerning treatments and their cost, efficacy, and impact on quality of life.
As principles of evidence-based surgery become more widely used, the methods used by
various stakeholders may converge although differences in perspective will continue to lead to
divergent priorities in outcomes research.
REFERENCES
1. Blaiss MS. Outcomes analysis in asthma. JAMA 1997;278(22):1874–80.
2. Health Care Financing Administration. National Health Expenditures, 1998. Table 3a. National
health expenditures and average annual percent change, by sources of funds: selected calendar years
1970–2008 [accessed 1999 Dec 16]. Available from: URL: http://www.hcfa.gov/stats/nhe-proj/.
3. Health Care Financing Administration. National Health Expenditures, 1998. Table 1. National
health expenditures and selected economic indicators, levels and average annual percent change:
selected calendar years 1970–2008 [accessed 1999 Dec 16]. Available from: URL:
http://www.hcfa.gov/stats/nhe-proj/.
4. Urban Institute. The uninsured: variations among state and recent trends. John Holahan testimony
to Committee Ways and Means, Subcommittee on Health, U.S. House of Representatives. Available
from: URL: http://www.urbaninstitute.org/TESTIMON/holahan6-15-99.html.
5. Pennsylvania Health Care Cost Containment Council. Consumer guide to coronary artery bypass
graft surgery. 1995 Jun 9 [accessed 1999 Dec 16]. Available from:
URL:http://www.phc4.org/reports/pr_cabg.htm.
6. Guice KS, Lipscomb J. Principles of outcomes analysis. Chapter 4. In: Stringer MD, Oldham KT,
Mouriquand PDE, Howard ER, editors. Pediatric surgery and urology: long term outcomes.
Philadelphia: W.B. Saunders Company; 1998. p. 23–38.

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CHAPTER 3

Table 3–1 Health Care Payers and Stakeholders

Health Care Funding Scenario Payer Insurer Network-Defining Entity

Self-funded employer using a TPA Employer Employer MCO

Employer purchasing an indemnity Employer Insurance Insurance company

Employer purchasing an insured Employer MCO MCO

Medicare (traditional) Federal government Federal Medicare program

Medicare (HMO) Federal government MCO MCO

Medicaid (HMO) State and federal MCO MCO

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