Welcome to the VEIN Magazine Podcast with Dr. Steve Elias, where vein specialists sit around, having drinks and talking.
Drs. Margaret Mann and Marlin Shul join Dr. Steve Elias to discuss the Improving Wisely Pilot Project, an initiative aimed at using the power of comparison feedback and peer education to curb the overutilization of superficial vein procedures.
How was the Improving Wisely Pilot Project conceptualized? Where is the data coming from and how is it used? Will it actually change physician behavior and improve patient care? Listen now or read the transcript to find out this and more.
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Dr. Steve Elias: We're sitting here, just a couple of vein specialists having drinks and talking. Unfortunately, the drinks are not alcoholic at this point. Dr. Margaret Mann, who is the author of a recent article in VEIN Magazine, is with us to discuss the Improving Wisely Campaign from ACP. Margaret, what are you drinking?
Dr. Margaret Mann: I am having Zen tea.
Steve: Zen? Okay, is it making you zen?
Margaret: Yeah, I'm very zen-like. I'm very calm and collected.
Steve: You are calm and collected. Speaking of calm, Marlin Schul, Mister relaxation, what are you drinking here?
Dr. Marlin Schul: Just an ice cold water.
Steve: Ice cold water. Okay.
Marlin: Very refreshing.
Steve: Yes, and I'm having some tea too. What was it that I had?
Steve: Okay, so we're all sitting around having drinks—talking. We're speaking from the annual ACP (American College of Phlebology) meeting, which is at the Gaylord Palms Hotel, or shall we say complex, or...
Steve: Nation or whatever town. It's a facility that's really nice. Have you been outside yet, Marlin Schul?
Marlin: Just once.
Steve: Really outside? Or, in the fake outside?
Marlin: Once. No, once. Very first day. Otherwise, you don't have to really. Everything's really right here onsite.
Steve: I know. They fool you into thinking you're outside.
Margaret: Nor do you want to go outside. It takes you about half an hour to go from one place to another.
Steve: Right? That's true. So, we're all inside here, speaking, and one of you has to tell the listeners what the Improving Wisely Pilot Program is, or how it was conceived? Who was the conceptualization of this? Who did it?
Margaret: Last year, at the ACP meeting, we were talking about ethical standards and about overutilization. The fact that we all see physicians doing ablations—eight per limb—and various things where it's not the best way to treat our patients, we said, "What can we do as a society to reduce overutilization?" In my specialty of dermatology, Improving Wisely has helped reduce utilization of most surgery. I thought this would be a great project to bring to ACP to try to reduce the utilization of thermal ablations and codes in our group. That's kind of where it came from, and it's been a great project for us. I think it should hopefully make a big impact on our world.
Steve: Well, we hope so. Incoming president of the ACP, Marlin Schul, what do you think about how our members might respond? We're going to get into some of the data that Improving Wisely has, but how do you think they will respond to data? Tell them what data they're going to get from Improving Wisely.
Marlin: Everyone is going to get an individualized report, helping them understand what their utilization rate is per patient. Now, this is the number of procedures performed per patient that had thermal procedures over the course of 2017.
Marlin: This is what the claims-based data shows. This means these procedures were performed, and from that standpoint, it should be a fairly reliable metric. What's not known is the disease severity of these patients. So, if someone looks at this and they find that they're an outlier but they operated in a wound clinic, my guess is, they're going to be doing more of these procedures because they tend to have a bigger burden of disease. It's an education tool is what it's used for.
Steve: We had another one of these podcasts with people discussing how we use data and, as a matter of fact, that's the main lead article for VEIN Magazine’s most recent issue. But where are you getting your data to make the conclusions that you're going to be sending out? Where is this data coming from?
Margaret: So, this is publicly available data from the CMS. We all know, and this is all captured by the Center for Medicare and Medicaid. We know how many ablations each physician's performing. What's great about Improving Wisely is, because this is a joint project with Robert Wood Johnson Foundation and Johns Hopkins, they actually have real-time data.
Margaret: We all, if you log into the CMS website, can get each physician's data on an excel sheet, which is probably 100 megabytes. It's hard to download, but you can actually get that data out there. The problem with that is, it's old data from 2013-2014. This is real-time data, and what we've done is we've been able to isolate each physician and specifically target how many ablations per limb.
Margaret: It's all out there, but I think what's powerful about this isn't just to say what the average is but what each physician is doing right. I think, number one, we want to figure out what the benchmark is—what is the average? But more importantly, where is each physician in relation to that benchmark and where are we on the curve? There've been great studies out there that show the importance of peer comparison feedback. The whole idea is, you're not just trying to figure out what the middle is, but you want to figure out where each person is in relation on the curve because then, we're all competitive, we all want to be number one. So, hopefully, this program allows us to do that, to move toward the middle.
Steve: Alright, so each physician is going to get information. Now, are you all going to know who's looking at the data? What that physician's name is?
Margaret: Yeah. What's...
Steve: You know what, Margaret?
Margaret: Yes. Oh!
Steve: How about Marlin Schul? See, Marlin Schul is very polite, everybody. He's always quiet; he doesn't like to jump in on things. Sometimes I'm not sure if I'm offending him when I'm speaking because he doesn't say anything, or if he's being quiet.
Marlin: Oh, no.
Steve: So jump in here, Marlin Schul.
Marlin: I'll tell you what: Margaret's got a lot of experience with this, and so I was just going to let her take the lead. But the reality is, this is all confidential data. Although you can get this on the public domain, nobody on the Physician Engagement Council sees any names.
Steve: Is this right? The data are going out to members of the ACP, it's not going out to every single person in the country that's doing ablations in the CMS system.
Marlin: It is going out to others that are not ACP members.
Marlin: Yes, sir.
Margaret: Yeah, as part of the CMS data, we actually have their building location and all of that. We are going to be able to give a report to every physician who does more than 10 ablations per year.
Steve: And you're couching this under the aegis of the ACP?
Margaret: Yes, and the Improving Wisely Project. This is, again, a national organization that does this in many other societies. The American College of Cardiology, the Gastroenterology Group, they all have similar projects. The goal is, again, to allow physicians to get peer feedback, to help them figure out a way to get toward reduced variability.
Steve: So, you're hoping to change physician practice patterns based upon giving them knowledge about how they compare to others?
Steve: You said there obviously is data in the dermatology world, and there's data that changes patterns.
Margaret: Mm-hmm (affirmative).
Steve: We know, in the arterial world, from the SVS VQI, that changes patterns as well. Has there been any pushback in any of these, if you know of it? Are there any areas where some physicians say, "Hey, what the hell are you looking at my information for?" Has there been any pushback from anybody?
Margaret: In the Mohs College, it was actually very well-received. Actually all physicians. There was not. I actually talk to the organization quite a bit in the council there. I think there's power with knowledge, right? Are there some physicians who are outliers, who may go, "I know the reason why I'm doing this." I think there's something about reflection, that even though you're higher up, that perhaps you kind of think about it and you figure out, "Hey, why am I an outlier?" I think it's, again, not punitive. It's not meant to change credentialing; it's not meant to change how you practice. This is a personalized, confidential report to show where you are compared to your peers.
Steve: Go ahead.
Marlin: I think it's also important too to discuss how you define an outlier, because the curve is the curve, and the way the outliers have traditionally been identified is two standard deviations from the mean. When you take that, that means there's not going to be a ton of true outliers, but it is going to give everybody a sense of where they stand in relation to the curve. From that standpoint, this has been a hot topic as you know. We've been talking about it for years. Instead of having a punitive way to identify these patients, it was more about trying to help them understand whether or not they may be under scrutiny, based on their utilization patterns.
Steve: Do you have the average that you came up with?
Margaret: It's 1.9, which is what you guys found too, right?
Steve: Yeah. Exactly.
Margaret: Then, the median was 1.7. I mean, that data is out there. No doubt, that's what we found. But again, I think the power of this is to look at the individual...
Steve: Let people know.
Margaret: Right, and where you are on the curve. We looked at it. If you look at everybody greater than 10 ablations, the total number was 2,642 physicians.
Steve: Out of how many?
Margaret: That's how many physicians do more than 10 ablations.
Steve: Oh, okay. I'm sorry.
Margaret: And then...
Marlin: On Medicare patients.
Margaret: On Medicare patients, right. So, 2,642 physicians qualify as doing more than 10 ablations. Then of those who are greater than two standard deviations, there's about 106.
Steve: Do the math with me. At what percentage would you call our outliers? 2,000 over...
Margaret: Less than 5%.
Steve: Right, less than 5%.
Margaret: It really isn't a big number, right?
Margaret: But what's also incredible is, at least with the Mohs data, we find that even those who are not outliers, who are maybe just one standard deviation above the mean, if you track their performance over time, they all gradually come back to the mean. That's the power of it, right?
Margaret: 'Cause if we know that there's overutilization, whether it's a little bit or a lot, I think it allows us to reflect on it and say, "What can I do to improve my practice?"
Steve: No, I think it's excellent. Are you thinking of, once you kind of show how this changes practice patterns with the CMS and Medicare populations, go to the private carriers who have the data as well?
Margaret: Yeah. That's always a bit tougher to do, but if we can capture that, that would be great. I think—again, this has been shown in other societies—if you look at Medicare data, it's pretty representative of what happens in private. 'Cause someone who's an outlier isn't going to only be an outlier...
Margaret: Per se, in Medicare. You could look at private data, but I think this is pretty good. Now, what we are looking to do in the future is to look at other metrics. This is the lowest hanging fruit—thermal ablation per limb or per patient. Next steps could be things like the number of ultrasounds you do, and then how many of those go on to get endovenous ablation. Or for ulcer patients, and how many of those get treatment. With deep venous disease, we haven't even explored that. There's a lot of possibility for us in this data.
Steve: Yeah. I think, again, the main theme of the recent VEIN Magazine is the power of data and how it can help us to, hopefully, decrease the overuse, and at times abuse, of any vein procedure at all.
Steve: What I see, and I've approached a number of the private carriers in our area, as well as Tony Gasparo has approached those in his area of New York, and mine in New Jersey, giving them what the average number of ablations are per limb. They can use that data to at least look at those people who are in their system that are outliers as well, and again, just letting them know that we're looking at you. And, we’re giving them the information. I think this is an excellent way of subtly and nicely—without being punitive in the beginning—changing people's patterns. There's no reason to think it's not going to happen. It will happen.
Margaret: Absolutely. Face it, I think Medicare and private carriers are all looking to reduce how much they're spending. If we don't find a way to do it ourselves and figure out a way to minimize our utilization, they're going to come and give us regulations. I think this is a great way for us to say, "Hey, these are normal benchmarks. Where are you at?" And as a group, figure out a way to reduce our use before they come after us, regardless of whether we want to or not.
Steve: Right. What's the lag time to changing people's patterns? In the Mohs surgery thing, when you sent out the information, how long did it take for you to see a change in practice patterns?
Margaret: They actually saw it within one to two years.
Margaret: Yeah. Pretty much we had our initial date—I could be wrong with the year— in 2015, but by even 2016, they saw a drop. Interesting with the Mohs College, they only sent it to members, and they were able to look at the data between members and non-members. I think the word got out, and we know what the average is now. What they saw was actually a dip—not just in members but also non-members— their patterns.
Steve: Are you thinking of getting this data out? 'Cause the more data we have published or presented at various meetings, the more people will become aware of this. We've published our data regarding the Medicare database in 2012-2015, and now you have more real-time data and stuff. Are you planning on doing this at some point?
Margaret: Yes. We are writing the manuscript as we speak.
Steve: No, you're not writing as you speak, you're talking to me as you speak.
Margaret: Well, it's ruminating in mind. But yes, we're hoping to get it all published before the end of the year.
Steve: Okay, good, because it's really going to help us. Now, are you going to roll this out? Today's day one of the ACP meeting. When are you letting our members know what's going on?
Margaret: It's going to be right after the meeting. The reports are being printed as we speak. We wanted to be able to come here and introduce the project...
Steve: Aren't you going to be introducing it at the meeting?
Margaret: Exactly. We'll be there tomorrow.
Steve: Yeah, that's what I wanted.
Margaret: After that, pretty much in the next couple of weeks we're going to be sending out the letters.
Steve: How many people are helping you write this thing?
Margaret: The letters?
Steve: No, not the letters, the ones you get about the data.
Margaret: Ah, the Improving Wisely group. There are several folks on there who have been instrumental in helping us with this. Marlin Schul and I are both on the paper, and then the Improving Wisely group.
Steve: Where is this Improving Wisely group based out of?
Margaret: They are based at Johns Hopkins.
Steve: Okay, they're at Hopkins.
Margaret: Yeah, they're at Hopkins. Marty McKerrie is actually the brainchild of this.
Margaret: He is actually phenomenal. He has been interested in transparency and the whole idea of big data for a long time. He is actually a surgeon at Hopkins, and he's kind of the guy who thought of, “How do we look at benchmarking and how do we do peer comparison?” I met him at our Mohs College and thought it would be a great project for us.
Steve: I think it's great. We're all looking for two things. One, obviously to change the patterns of people who are not doing things correctly. But two, trying to use the data for our members and members of other societies who are doing the right thing, so to speak, to continue to be able to take care of patients who have the problem. And, as you already said, the only way we're going to prevent insurance companies from having the knee-jerk reaction of, "We don't understand what's going on, we're just going to stop paying"...
Steve: Before that becomes an alternative, we need to show them the data and show that it changes people's practice patterns.
Steve: How can we get a better insight and working relationship with the payers themselves? With the data, do we just show them the data? Or, do we volunteer to help them understand how they can utilize this data within their own cohort of physicians who are treating venous disease?
Margaret: I think, first off, is getting the data out there. I would be happy to help payers figure out how they can or how the data translate into their individual patient population. I think both. I would love to collaborate with them. I think anything we can do to improve vein care without increasing regulation, is important. So rather than that knee-jerk reaction of saying, "Well if everyone's doing too much, let's not cover anything," think "How do we best cover the patients that we need to treat?"
Steve: So how about the deep system? I think we should tackle that as well.
Margaret: I agree. Give me some ideas? What should we do? 'Cause Marlin Schul and I were just thinking about that. I'm not a deep system person, so you tell me.
Steve: No, but it's a data-driven...
Margaret: Do you think it's stents? What do you think, the number of stents?
Steve: Yeah. I think it's the number of patients per number of stents, not number of stents per patient. The number of patients stented. Because many times when you stent an iliac vein you're going to use more than one stent.
Steve: That's not a fair way of doing it, but you need to get the denominator, and that's something that we don't have, even in the superficial world. In other words, what percentage of patients who are seen should appropriately be treated versus if one practice is seeing whatever number of patients and they're treating 90% of them? You and I both know that's off the chart.
Steve: Should they be seeing, ostensibly, 100 patients and 50 of them ultimately wind up having some procedure? Should it be 40? Should it be 55%? Can that data be gotten from this database?
Margaret: We can. Yeah, we can. The nice part is you can actually look at ICD-10 codes specifically, using that as the denominator and the number of procedures as the numerator. But specifically for stenting, is there a specific code that's frequently used to identify all those patients? 'Cause that's what we would need.
Steve: If they use iliac vein stenosis, yes. But I agree with you, it would be a little bit harder because ICD-9 can be all over the board. It may be a little bit tougher with the stenting, but we know that there's going to be more and more abuse of stenting and deep venous interventions the more people move it out of the hospital system without being looked at. I think we should delve a little deeper since 80% of people who we see wind up having a superficial disease. I think you should try and get a little more of the denominator.
Steve: To get a better idea as to what's going on so you can see which people are also outliers regarding the percentage of people they treat who they see.
Margaret: Yeah. One thing we could do, and we're looking into this, is that second stage: Which is the number of patients who have ICD-10 that identifies them as varicose veins, the whole gamut of codes, and then looking to see how many of them. Then, what percentage go on to get endovenous ablation? That's kind or our...
Steve: Or, any kind of intervention.
Margaret: Yeah. Exactly. Sclero or phlebectomy, or any of those.
Steve: I think that would be a great thing for people to know as well because not everybody treats venous disease with endovenous ablation. They may decide they're going to do some sclerotherapy or phlebectomy, or something like that. I think this is a great step, and it's the beginning. Hopefully, the more data we have, the more the payers know we're looking at this too, and we're trying to change practice so they don't have to just say, "You know, forget it. I'm just not covering C2 disease because we can't get a handle on it." I think there's a great way to handle, and I think you, Marlin Schull, and the whole Improving Wisely team, are on the right track.
Margaret: Thank you.
Steve: Thank you for being here. We've finished our tea because it's very cold in this room. We'll move on to bigger and better things. Thanks again, Margaret.
Margaret: Thank you.
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