Quality Care, Affordable Care: How Physicians Can Reduce Variation and Lower Healthcare Costs

Table of Contents

• Chapter 1: Unwarranted Variation
  • Preference Versus Supply
  • Warranted Versus Unwarranted
  • Value
  • Affording the New
  • The Dartmouth Atlas
  • McAllen, Texas
  • Isn’t This Rationing?
  • Something Different
• Chapter 2: Inappropriate Use
  • IHI’S Framework
  • The Prototyping Community
  • PAMF at IHI
• Chapter 3: The Inefficiency of “Efficiency”
  • Tiering the Network
  • Aetna’s Black Box
  • Cost not Efficiency
  • Are the Data Wrong?
• Chapter 4: Variation Reduction
  • The Prehistory of Variation Reduction
  • Variation Reduction 0.1
  • Variation Reduction 1.0
• Chapter 5: Our Results

Part II: Changing Minds, Changing Practices

• Chapter 6: Why Bother?
• Chapter 7: Addressing Physicians’ Concerns
  • “Won’t This Lower My Income?”
  • “Won’t This Skew My Stats?”
  • “Won’t This Hurt My Productivity?”
  • “Won’t This Interfere with My Autonomy?”
  • “Isn’t This Just ‘Cookbook Medicine’?”
• Chapter 8: Growing Local Experts
• Chapter 9: Understanding Variation
• Chapter 10: Pillars of Variation Reduction
  • Affordability Is the Answer
  • Value
  • You’re the Experts
  • They’re the Experts, Stupid
  • “We Can Get You That Information”
  • “We Didn’t Say It Was Perfect”
  • The Foundation

Part III: Variation Reduction by the Book

• Chapter 11: Is Variation Reduction Right for You?
  • Robust Data
  • A Workable Group Structure
  • Physician Engagement
• Chapter 12: Working with Data
  • Start with Targeted Groups of Physicians
  • Gather a Lot of Patient Data
  • Filter Down to Data That’s Comparable
  • Attribute the Data Consistently
• Chapter 13: Analyzing and Communicating Variation
  • Analyzing Variation
  • Communicating Variation
  • Personalizing Variation
• Chapter 14: Herding Cats
  • Two Productive Meetings
  • The Meeting From Hell
  • Set Up the Right-Sized Meeting
  • Make the Meeting Happen
  • Structure the Meeting
  • Adapt to Participants’ Needs
  • Foster Synergies
  • Write a Standard of Care
  • Spread the Standard
• Chapter 15: Solving Problems
  • Getting to the Heart of the Matter
  • Minding the Gaps
  • Turning Over the Stone
  • Training Variation-Reduction Champions
  • Helping the Physicians Choose
  • Insisting on Value
• Conclusion
• Endnotes

Lawrence Shapiro, MD is a board-certified physician with a specialty in pulmonary medicine. For the last twenty years, he has been enmeshed in the healthcare system known as Managed Care. As a result of these experiences with physicians, medical groups, hospitals and health plans, he initiated the Variation Reduction Process at the Palo Alto Medical Foundation, which has reduced the cost of healthcare while increasing quality.

Erica Weirich, MD
Director, Global Health Research Foundation Adjunct Clinical Assistant Professor of Medicine Stanford University School of Medicine

"In his new book, Quality Care, Affordable Care, Dr. Shapiro provides a novel solution to bending the cost curve and improving patient outcomes, a physician's perspective and recipe for success in an increasingly value conscious health care market. The book provides much needed fresh insight that takes the mystery out of medical cost reduction through a practical program of variation reduction - and puts the solution back in the hands of physicians. As an experienced physician and health care administrator, Shapiro provides his proven formula for eliminating unnecessary, costly and potentially risky medical care while providing greater value to the patient through improved outcomes."

Karl G. Sylvester, MD
Associate Professor of Surgery and Pediatrics
Executive Director, Center for Fetal and Maternal Health Lucile Packard Children's Hospital
Stanford University School of Medicine

"Formal guidelines are applicable to only a small fraction of clinical practice. Dr. Shapiro engagingly shows how groups of physicians asking questions about variations in their own practices can develop, and then adhere to, their own guidelines. Creating such learning healthcare systems is the best way to increase value in health care."

Harold S. Luft, PhD
Caldwell B. Esselstyn Professor Emeritus of Health Policy and Health Economics University of California, San Francisco
Author, Total Cure: The Antidote to the Healthcare Crisis