Friday, July 27, 2012

Teaching Costs of Care: Opening Pandora's Box

Dr. Arora is an associate professor of medicine and Assistant Dean for Scholarship and Discovery
at the University of Chicago Pritzker School of Medicine

Last week, I tried something new with our residents…we tried to talk about why physicians overuse tests. This is the topic of the moment, as the American College of Physicians (ACP) just dropped their long-awaited new High Value Cost Conscious Curriculum for what has now been dubbed the “7th competency” for physicians-in-training. In addition to the ACP curriculum, which I served as one of the reviewers for, I also am involved with another project led by Costs of Care to use video vignettes to illustrate teaching points to physicians in training about costs of care called the Teaching Value Project. With funding by the ABIM Foundation , we have beenable to develop and pilot a video vignette that that depicts the main reasons why physicians overuse tests. The discussion was great and the residents certainly picked up on the cues in the video such as duplicative ordering, and that the cost of tests are nebulous to begin with. But, before I could rejoice about the teaching moments and reflection that we created with the video, I must admit that I felt like Pandora opening the dreaded Box. Many of the questions and points raised by the residents highlight the difficulty in assuming that teaching doctors about cost-conscious care will translate into lower costs and higher quality.

1) What about malpractice? One of our residents mentioned that really the problem is malpractice and that test overuse was often a problem due to the “CYA” attitude that physicians have to adopt to avoid malpractice. It is true that states with higher malpractice premiums have more spending on care. However, this difference is small and does not fully explain rising healthcare costs. More interestingly, the fear of being sued is often more powerful than the actual risk of beingsued. For example, doctors’ reported worries about malpractice vary little across states, even though malpractice laws vary by state.

2) What about patients who demand testing? Another resident highlighted that even with training, it was often that patients did not feel like anything was done until a test was ordered. Watchful waiting is sometimes such an unsatisfying ‘treatment’ plan. As a result, residents reported ordering tests so that patients would feel like they did something. In some cases, patients did not even believe that a clinical history and exam couldlead to a ‘diagnosis’ – as one resident reported a patient asked of them incredulously, “well how do you know without doing the imaging test?”

3) What can we do when the attending wants us to order tests? All of the residents nodded their head in agreement that they have had to order a test that they did not think was indicated, because the attending wanted to be thorough and make sure there was nothing wrong. I find this interesting, since as an attending, you are often making decisions based on the information you are given from the resident – so could it be that more information or greater supervision would solve this problem? Or is it that attendings are hard wired to ask for everything since they never thought about cost?

4) Whose money is it anyway that we are saving? This is really the question that was on everyone’s mind. Is it the patient’s money? After all, if a patient is insured, it is easy to say that it’s not saving their money because insurance will pay. Well, what about things that aren’t even reimbursed well..doesn’t the hospital pay then? Finally, a voice in the corner said it is society that pays – and that is hard to get your head around initially, but it is true. Increased costs of care are eventually passed down to everyone – for example, patients will be charged higher premiums from their insurance companies who are paying out more. Hospitals will charge more money to those that can pay to recoup any losses.

5) Will education really change anything? So, this is my question that I am actually asking myself at the end of this exercise.… Education by itself is often considered a weak intervention, and it is often the support of the culture or the learning climate that the education is embedded in. The hidden curriculum is indeed powerful, and it would be a mistake to think that education will result in practice change if the system is designed to lead to overordering tests. As quality improvement guru and Dartmouth professor Paul Batalden has said (or at least that’s who this quote is often attributed to when its not attributed to Don Berwick) “Every system is perfectly designed to achieve the results it gets.” Therefore, understanding what characteristics of systems promote cost conscious care is a critical step.

However, before we dismiss education altogether from our toolbox, it is important to note that education is necessary to raise awareness for the need to change. And in the words of notable educational psychologist Robert Gagne, the first step in creating a learning moment is getting attention. And, by that measure, this exercise was successful – it certainly did get attention. Yet, it also did something else…it created the tension for change, a necessary prerequisite for improvement. It certainly cultivated a desire to learn more about how to achieve this change….which is what our team is currently working towards with the Teaching Value Project. So while learning why tests are overused is a first step… judging by Pandora’s box, it is certainly not the last.

--Vineet Arora MD MAPP


  1. Dr. Arora and all contributors,

    First, I wanted to say I deeply appreciate your concern and commitment to the Costs of Care project as well as your charges, whether they are students or patients.

    As someone with no ties to the health care industry-- though I've had a goodly amount of experience as a young patient with employment-related medical insurance-- I'm curious if anyone is able/willing to offer thoughts on the following question:

    What is the general consensus of doctors across the United States when it comes down to the issue of health care costs?

    I don't mean for that question to sound rude, as obviously everyone following this site is aware and concerned. But sometimes when I go in to see my own doctors, they don't seem to have the same line of thinking. The general process for an office visit is to give me approximately 15-minutes, prescribe a drug or order tests, then send me on my way. There doesn't seem to be much thought given to what the tests or drugs will cost me, or what the costs are to the 'system.'

    Recently, I completed a CT scan that I think was likely unnecessary since earlier blood and stool tests were normal. In addition to the $83 I paid upon check-in (not sure what was paid by myself and my employer via insurance), I also spent 2.5 hours to come in early to drink the designated beverages and undergo the scan. Though the highest cost, in my mind, was the few weeks of anxiety I experienced worrying about why I had to do the scan, the potentially unnecessary radiation exposure, and of course the result.

    Thankfully, the result was normal, but I'm still not sure why the test was ordered; and a part of me is conflicted over whether or not my doctor cares about the aforementioned costs.

    In summary, my questions boil down to: How much do doctors across the country care about costs? Is there anything tangible that patients can do to help their doctors as well as themselves?

    Thank you for reading!

    1. Guessing no one has time to or wants to posit a response.:)

      My main thought is, if the vast majority of doctors--as the 'front line' experts dealing directly with patients--are not aware of or do not particularly care about costs, the system cannot actually begin to improve.

      As a paying patient, I know now that at the very least I should always ask "Why?" and "How much will this cost?" instead of automatically assuming I'll get the best thought out medical opinion on health care options.

  2. thanks for posting..