The Letterman Approach to Cost Awareness

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 their national “High Value, Cost Conscious Care” curriculum. 

Who doesn’t love a Top 10 list? Creating them is an art form.  So when it was formally proposed by Dr. Brody in 2010 in the NEJM that each specialty create their own “Top 5 list” of unnecessary care, it seemed like a straightforward – if not downright provocative – suggestion.

“The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit,” he wrote.

And yet, thus far the only groups that have seemed to have taken him up on the suggestion have been the primary care specialties of Internal Medicine, Family Medicine and Pediatrics - notably amongst the least compensated fields in health care.

 This is a great start, but c’mon guys, where are the rest of you? Dr. Brody wrote you a “prescription.” We have a term for your behavior: “noncompliance.”

Not to say that there hasn’t been some progress. The ABIM Foundation has indeed put together an impressive list of organizations participating in their “Choosing Wisely” campaign. They also have begun to be instrumental in funding projects towards this goal. Costs of Carehas highlighted far-reaching areas of non-value-based care, including a recent thoughtful essay about robotic surgery. We must now consolidate on these small gains and move this forward across all specialties in medicine.

It is worth noting that one of our first steps in creating our curriculum at UCSF was to come up with our own list. Not quite a Top 5 list, but rather a list of 12 “core topics” which we would explore each month over the course of the year. These were to be commonly encountered Internal Medicine clinical scenarios with frequent practice and resource-utilization variability, including syncope, chest pain, low back pain and pulmonary embolism (see complete list below). 

Just this past week, we reviewed and discussed a case of cellulitis, in which the patient (who admittedly was a dialysis patient with an indwelling tunneled central venous catheter) had five (yes, five) negative blood cultures drawn within the first 24 hours of his hospitalization, for his left leg cellulitis.  He was hemodynamically stable and was being treated on a general medical floor. The costs, lab work, biological waste, and potential downstream effects - risk for false positives from contamination leading to further testing or line removals, the pain of multiple venous sticks and the small risk of phlebitis, etc - of these unnecessary and unwarranted tests are substantial.

Now, as with any list, I suspect that there will be many different opinions. The “but you forgot about…” “how could you leave off…” and “I don’t understand why that is on the list…” reactions are par for the course.

But, perhaps what was most notable about the creation of this list was exactly how non-contentious the process was. When we asked the group consisting of a few UCSF residents and hospitalist faculty to identify areas ripe for a “cost awareness” review process, the ideas came quickly and easily. The fruit was low-hanging enough to kick them into the basket. Perhaps a testament to the waste that we see all around us every day.

Explicitly identifying areas to focus on should be the first check box on all of our cost awareness to-do lists. Let’s all start making some lists.