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Let's Review: How to Get Timely Evidence in the Hands of Policymakers
Today many different groups agree that public policies must be based on evidence to achieve their goals. Indeed, the mandate of the Commission on Evidence-Based Policymaking is to find ways to increase the use of evidence and data in federal policymaking. But where do policymakers get objective evidence that can inform their decision making?
One way for researchers to provide relevant information to decision makers is to perform a systematic review of the published literature on the topic. Systematic reviews involve conducting methodical database searches to synthesize and assess the quality of research on a given subject. This methodical approach does pose a challenge: it can take many months to complete. Rapid reviews attempt to address this problem by incorporating some of the features of a systematic review, like the use of a structured search strategy, but omitting others, such as a multiple language search, which can extend completion time while providing little added benefit. This approach produces quality, timely evidence, although it’s typically not as complete as a systematic review and risks excluding relevant evidence.
I recently published a rapid review of literature looking at the impacts that physician payment methods can have on health care practice, specifically how they affect health care costs and outcomes. Several articles on fee-for-service (FFS) payment systems demonstrated that, in addition to the well-known problems of over-diagnosis and treatment, FFS can also result in the inconsistent application of health care services. This is because providers practice independently, with few systems in place for developing treatment protocols and practice reviews. Another article discussed predictions of health insurers that variations in treatment practice will be reduced through increased use of prospective or bundled payments systems, in which providers are paid a lump sum for a bundle of services required by a diagnosis (for example, surgery and post-acute care for a hip replacement). These systems would be accompanied by clinical pathways or management plans that preserve quality by stipulating the sequence and timing of actions required by the associated diagnosis. This approach’s design curtails the financial incentive to provide ever more care while ensuring hospitals won't jeopardize quality by providing too little care.
This rapid review serves as an example of how researchers can provide high quality and timely information on critically important and complex policy topics. The Affordable Care Act is leading the shift away from FFS and toward value-based payment systems, a response to the perverse incentives inherent to FFS reimbursement. New legislation that took effect last year, the Medicare Access and CHIP Reauthorization Act (MACRA), starts the shift from FFS to bundled payment as the payment method for physicians who treat Medicare patients, a huge proportion of the patient population.
Among its many efforts to contribute to better understanding of major health policy initiatives, Mathematica provides data analytics support and technical assistance in the MACRA implementation, including calculating which participating physicians are eligible to receive annual incentive payments of five percent of their professional services from the previous year. In addition, we are working with the Center for Medicare & Medicaid Innovation to calculate the size of the payment that hospitals receive when they participate in an episode-based payment program. The payment is meant to cover all the costs incurred by the hospital for one episode of treatment; variations in the payment correspond to the hospital’s performance on measures of care quality and factors such as the hospital's location and case mix. Mathematica also recently won a contract to monitor the program for unintended consequences in hospital behavior, such as whether hospitals are more selective in the patients they treat, and whether they document diagnoses in ways that will enhance payment (but not patient care).
Much recent legislation has focused on reforming physician payment methods to address the high levels of spending in the American health care market. But physicians could argue that policymakers haven’t used evidence to identify the key drivers of spending, since less than 20 percent of health spending goes to physician services, and physician wages have grown slowly since 1990. Changes in this area might not translate into changes in the rate of growth in health care spending. Our project with the Center for Medicare & Medicaid Innovation focuses on changing payment methods for hospitals; perhaps this is a more sensible area of focus because hospitals account for 50 percent more health care spending than doctors.
As the policy landscape in health care and other key areas continues to evolve, researchers must provide rigorous, objective evidence and tools to help policymakers make decisions that impact the citizens they serve. Evidence in the form of systematic and rapid reviews can improve the policymaking process and in turn the public good.