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A Clear-Eyed Approach to Reducing Costly Health Care Regulations

Johns Hopkins ophthalmologist Oliver Schein has found a simple way to save a half a billion dollars a year from our country's health-care bill, with no negative effect on patient health. The only thing standing in the way is a stubborn government requirement.

Seventeen years ago, Dr. Schein and colleagues published a study finding that cataract surgery patients who underwent routine preoperative testing — such as an electrocardiogram, blood tests and imaging studies — had no fewer complications than those with zero testing. The risks of this surgery are so small that they can typically be identified and handled on the day it occurs. Nonetheless, 53% of patients continue to receive testing as part of a preoperative medical exam despite robust evidence that this exam and testing does not reduce surgical risk for cataracts patients.

While this medical exam is not routinely performed before dental procedures, most endoscopies and office-based minor procedures, it continues to be required by the federal government and accrediting organizations before every cataract operation and other low-risk elective procedures. For cataracts, the costs of these mandatory exams is a roughly half a billion dollars annually. Among Medicare beneficiaries, no procedure is performed more than cataract surgery, which is projected to grow to 3.3 million surgeries a year by 2020.

Let me be clear: Requiring the preoperative exam makes sense for the vast majority of procedures. Patients can bring complicating factors to the operating table ─ multiple diseases and conditions, allergies, and complex medication regimens, to name a few. The exam helps the surgical team to plan a successful operation and identify and mitigate risks for potential complications.

Those risks rarely exist in cataract surgery. Patients get local anesthetic and mild sedation for a procedure that typically lasts 20 minutes. Often, they head home 15 to 30 minutes after the surgery. Patients who truly need a preoperative work-up, such as those with a recent hospital admission, can be identified easily with a checklist.

Obviously, the cataract example speaks to a larger issue. Health-care regulations have a critical role in ensuring patient and worker safety. Yet we need to bring a nuanced approach, seeking out medical evidence and expertise to show us where we can safely reduce the compliance burden.

Excess regulations also hurt clinician productivity and contribute to worker burnout. Physicians spend roughly half their time at work documenting in clumsy electronic medical record systems or doing other administrative work, according to a study published last year.

There are many health-care regulations that, if revamped, could help reduce costs while preserving or even improving safety. For example, it's more convenient and less expensive for otherwise healthy patients to get long-term intravenous antibiotics at home, rather than extend their hospital stays. This treatment, delivering the medications through a catheter on an outpatient basis, increases patient satisfaction and saves health care dollars.

Unfortunately, Medicare doesn't cover it. These patients are too active to qualify for home care. So they might have to pay $100 a day out of their own pockets to receive the services. Those unable or unwilling to pay have to visit a skilled nursing facility or infusion center, a situation that not only drives up costs but is inappropriate for these patients.

There are encouraging signs that regulators are looking harder at such issues. The Centers for Medicare and Medicaid Services (CMS) recently removed a regulation that prevented nutritionists from writing diet orders, rather than requiring a physician to enter them. The decision is expected to save hundreds of millions of dollars and physician time. Yet there are many issues like this that need to be remedied, representing billions of dollars in potential savings.

Wise regulations have accomplished much good in health care. Still, CMS should establish a process to identify, evaluate and revise or remove regulations that corset clinicians, increase costs and place burdens on patients without clear benefits to safety or quality.

This post first appeared in The Wall Street Journal


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

3 thoughts on “A Clear-Eyed Approach to Reducing Costly Health Care Regulations”

  1. Hello Dr. Pronovost,
    My understanding is that this post is about reducing government regulations that are not evidence-based for cost savings without sacrificing quality. Your first example of pre-operative risk stratification with testing prior to cataract surgery is compelling with regards to reducing unnecessary cost. However, I was left wondering how this ties in to government regulations? s pre-op testing before cataract surgery a government regulation? I don't believe the article included that information.
    Thank you,
    Krista Curtis, RN, MPH
    Portland, Oregon

    1. Krista: Thank you for your question, and for reading. The Centers for Medicare and Medicaid Services and other regulatory bodies require a preoperative medical history and physical within 1 month of surgery, including cataract surgery.

  2. This is really great, I totally love this blog. To save a half a billion dollars a year from our country's health-care bill, with no negative effect on patient health is truly something amazing. Thanks for sharing the blog.

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