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01-01-2013 | Article

Limited resources and surging costs demand appropriateness criteria

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medwireNews: Using clinical appropriateness criteria to prioritize care will contain costs by controlling the number of elective procedures and avoid overutilization of medical resources, according to a perspective article in The New England Journal of Medicine.

The Affordable Care Act will bump up healthcare use by 50 million people by 2014. "Just by that fact you have more people utilizing elective procedures," primary author Hassan Ghomrawi, from New York's Weill Cornell Medical College, told medwireNews. "We want to spend our limited resources on patients who really need [elective surgery] now and who can't have delays,"

Ghomwari expects there will be controversy within the profession as well as between different professions over how to establish standards that determine which patients need elective procedures more than others. "It's not going to be [an] easy task to get people at the same table to get this going," he said.

Currently, there is impetus from the American Academy of Orthopedic Surgeons to develop the appropriateness criteria. "If the profession comes forward and develops these criteria," Gohmwari claimed, "it's going to be more comprehensive and have less bias towards the insurer, who likely wants a criteria that maximize[s] their profits."

Identifying subgroups of patients who are likely to benefit the most from procedures can create benchmarks for reimbursement, which enhances access to care while keeping costs in check.

Maintaining sustainability of medical costs is a hot button issue as healthcare spending exponentially increases and the demand for medical resources is expected to jump over the next few years. When thinking about cost containment, Ghomwari wants tools to be in place that ensure necessary care is not affected when trying to cut spending.

"We hope that when the [policymakers] down in Washington are deciding on how they are going to cut down on spending that the rules and levers that they use are not entirely economic," Ghomwari said. "[Evidence-based appropriateness criteria] will be a tool to provide care that is necessary in spite of the fact that we might want to cut expenses."

Elective procedures, such as total joint replacement, are some of the most common inpatient surgeries in the USA; 1 million elective total hip and knee arthroplasties were performed in 2009. Ghomwari pointed out that demand for total joint replacement has increased not just because of an aging population but also due to obesity. "Now it's no longer concerning those who are 65 and older who are having [elective] surgery, younger patients are having the surgery [too]," he said.

By Peter Sergo, medwireNews Reporter