Cost Awareness in Health Care: An Idea Whose Time Has Come

Christopher Moriates, MD is a senior resident in Internal Medicine at the University of California San Francisco (UCSF). He is a co-creator of a cost awareness curriculum for residents at UCSF and is currently working with the American College of Physicians (ACP) on a national “High Value, Cost Conscious Care” curriculum. He will be starting a faculty position with the Division of Hospital Medicine at UCSF in July 2012.

“Nothing is as powerful as an idea whose time has come.” – Victor Hugo

It didn’t take that long during intern year to realize that something was wrong. As I signed so many orders that my signature, once proudly readable, began its gradual but clear progression towards more abstraction, I eventually started to wonder just how much all of these tests were actually costing my patients. After all, once you start checking boxes on an order sheet, the “calcium/phos/mag” just seems to roll off of the tongue. However, not just how much was this “costing” patients financially, but also in potential risks, harms and adverse effects.

I particularly remember being bothered when told by an Emergency Room attending physician that I had to get the Head CT on my 28-year-old male patient presenting with a benign-sounding headache and a normal physical examination, “unless you could go in there and tell him that you personally can guarantee him with 100% certainty that he does not have something bad like a brain tumor.” This did not seem like a fair bar to hop, particularly having put the M.D. after my name a mere few months prior. So I scribbled my name on another form and with the whisk of my pen subjected this patient to a normal CT head examination, saddling this young man with a significant amount of radiation and a hospital bill that now included an approximately $2,500 imaging charge. Nobody seemed to flinch, but it got me thinking.

I realized that considering cost was just not something that we were ever taught; “The reasons for this silence are historical, philosophical, structural, and cultural,” wrote Dr. Molly Cooke in the New England Journal of Medicine in 2010. And yet, it turns out that the ACGME officially states (under their Systems-Based Practice core competency) that “Residents are expected to… incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.” This frankly was just not happening, and I know that my training program was not the outlier.

But this has all started to change.

It is hard not to feel, as I read impassioned articles about cost and/or value in health care in the most prominent medical journals (The New England Journal of Medicine, JAMA, The Annals of Internal Medicine, The Archives of Internal Medicine) and the popular press (The New York Times, The LA Times, Bloomberg), that the movement is starting to reach a critical mass. To see a patients’ hospital bill broken down and printed with a heart felt commentary by their daughter in a newspaper would have likely been unimaginable a short time ago. The call-to-arms seemed crystal clear during a recent speech by Don Berwick.

As for me, I am trying to do my part. During the past year, along with Dr. Krishan Soni and Dr. Andrew Lai at UCSF, I created and organized a multi-faceted longitudinal curriculum for residents to teach cost awareness.

In these blogs to follow, I will aim to discuss the implementation of this unique curriculum, along with many of the stories and lessons that we have collected along the way.