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

Monday, July 23, 2012

“Go Ask Your Doctor…” – Educating Patients and Physicians About Costs of Care

Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California San Francisco (UCSF). During residency training he co-created a cost awareness curriculum for residents at UCSF and is an active member of the American College of Physicians (ACP) High-Value, Cost-Conscious Care Curriculum Development Committee. 

The New York Times said that I probably should skip my annual physical. The other day, Consumer Reports sent me something in the mail entitled, “Imaging tests for lower-back pain: Why you probably don’t need them.” It said that imaging is “often a waste of money” and raised concern about cancer resulting from the radiation. They also published an article subtitled “Learn when to say ‘Whoa!’ to your doctor.” The ABIM Foundation’s widely publicized “Choosing Wisely” campaign popularizes lists of various practices that “physicians and patients should question.”

Instead of “Go ask your doctor if Cialis is right for you,” may we actually start to see patients asking their doctor if they really need that test or procedure? Will patients themselves help curb health care waste? Well, you may say that I’m a dreamer, but I’m not the only one.

If you are a physician, you probably should be thinking about how the heck you are going to appropriately field these questions, while crossing your fingers that the patient doesn’t actually go so far as to ask you how much that medication or test is going to cost them (the illustration of the doctor taking a stab in the dark is just about right).

After all, this was likely never even on the radar during your training. Admittedly, some prominent folks in medicine question whether it even should be, as nicely shown in this brand new, balanced article in the New England Journal of Medicine, which also highlights the Cost Awareness curriculum that we (Drs. Krishan Soni, Andrew Lai, Sumant Ranji, and myself) have developed here at UCSF, and the inspiring work of Dr. Neel Shah and the Costs of Care organization.

Given all of this, I strongly argue that it is becoming increasingly obvious at this point that physician education is going to be a key “necessary, but non-sufficient” initial intervention in approaching high value care.

I will reappropriate an analogy that Bob Wachter, UCSF Chief of the Division of Hospital Medicine (and my new boss), quoted to our group today about a slightly-different, but related situation (paraphrased): “The medical world has one foot in the boat and one foot on the dock and pretty soon is going to need to decide to jump in the boat. It is pretty clear where the boat is going.”

Enter the new AAIM-ACP High-Value, Cost-Conscious Care curriculum, which officially launched just days ago on July 10, 2012. Some of the resources, including the successful case-based format and take-away lessons, from our UCSF Cost Awareness curriculum, were adopted and adapted for this exciting new curriculum. This AAIM-ACP ten-module series is freely available to anyone interested (with the completion of a very short registration form) at

The curriculum, developed under the leadership of Dr. Daisy Smith from the ACP, by a committee including Internal Medicine program directors, faculty and residents from around the country, consists of ten one-hour interactive sessions (an overview of this curriculum is provided). The modules are organized around real-life inpatient and outpatient cases including estimates of hospital charges. It is meant to be flexible enough to fit into different resident structures, such as morning report, noon conference, post-clinic conferences, or academic half-days.

I encourage you to go check it out.

Go ask your Program Director or Chief Resident if the high value care curriculum is right for you.  

Monday, July 9, 2012

Surgery at $147 per minute

Nate Johnson is a medical student at Tufts University and Maine Medical Center

The patient had a large abscess surrounding his spleen. On a large screen in the middle of the operating room, I watched a surgeon drain the fluid collection and remove the organ with small metal tools. 

I remember the surgeon navigating the complex anatomy with alacrity, handling the laparoscopic equipment with expert finesse, and quickly and confidently answering the battery of questions from the assisting medical student. To a young and reverent observer, this surgeon seemed to know everything.

So at the end of the case I asked how much the procedure would cost the patient. “I’m not really sure. It’s…kind of complex,” the surgeon vaguely responded.

Indeed, surgical procedure charges are confusing and consist of many different fees. There are fees for medications, instruments, and devices, there is the “initial” operating room fee, the recovery room fee (billed per hour), the anesthesia fee, the surgeon’s fee, and the operating room fee (billed per minute), among others.

But at the time I was surprised and a little disappointed that this surgeon – who expertly performed the surgery and had an incredible breadth of medical knowledge – had no idea what the patient would be charged. It just seemed like such a simple question. I decided to look into it myself.

As it turns out, the total charge to the patient in this case was $43,226.18. The patient was in the operating room for 3 hours and 31 minutes and was charged a $30,966 operating room fee. That’s just under $147 per minute! A closer look also revealed that, from incision to surgery end, the procedure lasted 2 hours and 35 minutes. This leaves 56 minutes of non-surgical operating room time.

Of course, this time is not squandered. Before the surgery begins, for example, anesthesiologists need time for induction, the sterile surgical field must be set-up around the patient, instruments have to be prepared, checklists have to completed, and the surgeons have to scrub in.

Yet the question must inevitably be asked: did all of this additional work require almost an hour? At $147 per minute, the question deserves serious consideration. And the answer should be anything but vague.