tag:blogger.com,1999:blog-35379100586678049442024-03-18T15:28:55.732-04:00Costs of CareAll doctors should understand how the decisions they make impact what patients pay.Sam Lorenhttp://www.blogger.com/profile/00278404325077711750noreply@blogger.comBlogger86125tag:blogger.com,1999:blog-3537910058667804944.post-59816798986440920022013-01-20T11:13:00.001-05:002013-01-20T11:13:10.574-05:00Our blog has moved!We have officially transitioned our blog from Blogger to Wordpress and will no longer be updating this site.<br />
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You can continue to follow our patient and provider stories, though leadership articles and updates at <a href="http://www.CostsOfCare.org/">www.CostsOfCare.org</a><br />
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<br />Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com317tag:blogger.com,1999:blog-3537910058667804944.post-38142986764293507422012-12-22T14:43:00.001-05:002012-12-22T14:43:39.191-05:002012 Essay Contest Finalists Announced!<br />
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For the third time, we asked patients, nurses, and physicians to send us anecdotes that illustrate the importance of cost-awareness in medicine. What was in it for them? A chance to shine a national spotlight on a big problem: doctors and patients have to make decisions in a vacuum, without adequate information about how those decisions impact the costs of care. Also in it for them was a chance to win one of four $1000 prizes.</div>
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We received more than 150 submissions from all over the country - New York to California, Texas to North Dakota, Alaska to Oklahoma. We will be reviewing the very best submissions with the help of our judges - former United States Secretary of Health and Human Services Donna Shalala, ethicist and former White House advisor Zeke Emmanuel, New England Journal of Medicine editor-in-chief Jeffrey Drazen, and New York Times columnist and surgeon Pauline Chen.</div>
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Congratulations to our finalists! All of their essays will be published on our blog early in the new year. </div>
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<strong>Providers:</strong></div>
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Robbie Fenster (Rhode Island), a Brown University medical student describes the power of the "need to know" and the challenge of talking to a patient about an unnecessary and expensive MRI</div>
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Dr. Brent Bauer (Minnesota), a professor of medicine at the Mayo Clinic discusses a patient who underwent many years of expensive tests for chronic pain before being correctly diagnosed and successfully treated for a stress disorder </div>
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Benjamin Robbins (Massachusetts), a Harvard Medical Student describes a patient he encountered in the emergency room who declines at CT scan after not being able to find out what it will cost</div>
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Ashley Phipps (Colorado), a medical student at the University of Colorado describes how a dedicated group of physicians and social workers helped a patient avoid a hospitalization by obtaining affordable antibiotics</div>
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<strong>Patients:</strong></div>
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James Bliwas (Ohio), the brother of a cancer patient who preferred to die at home describes his struggle to obtain insurance coverage for a visiting nurse</div>
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Erin Plute (Georgia), an Emory medical student discusses the challenge of being an informed patient and how getting a second opinion helped her avoid an unnecessary CT scan</div>
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Dayton Opel (Wisconsin), a medical student from Wisconsin who struggled to decipher his emergency room bill even after calling the medical coders and ER physician</div>
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David Goldman (New York), the husband of a young woman with a strong family history of breast cancer and BRCA1 mutation describes the struggle of trying to value a "quality year life" when making medical decisions</div>
Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com30tag:blogger.com,1999:blog-3537910058667804944.post-17122613699400994502012-10-31T10:20:00.000-04:002012-10-31T10:20:00.081-04:00Time to Fight Horrors of Healthcare Costs by Taking Charge of Teaching Value <!--[if gte mso 9]><xml>
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<span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">This Halloween, several creative costumes have emerged from
the zingers of the Presidential debates – </span><a href="http://cityroom.blogs.nytimes.com/2012/10/09/big-bird-costumes-in-demand-for-a-post-debate-halloween/"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">Big
Bird</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"> costumes are selling out like hotcakes. For a more do it
yourself look, here’s a recipe for </span><a href="http://blogs.seattleweekly.com/dailyweekly/2012/10/binder_full_of_women_halloween_costume_by_the_stir.php"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">Binders
full of women</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">.<span style="mso-spacerun: yes;"> </span>The debate
over the best way to contain healthcare costs have also been a central part of
the debates, and yet medical bills do not seem to make popular costumes. Maybe
that is because that unaffordability of healthcare is too horrifying for ironic
humor – even on Halloween. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">As we head into the election, patients are increasingly being
terrorized by runaway healthcare costs.<span style="mso-spacerun: yes;">
</span>Americans outspend our peers </span><a href="http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">two
to one</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"> and still seem to be worse off. We overtest and overtreat
to the point of absurdity.<span style="mso-spacerun: yes;"> </span></span><span style="background: white; color: black; font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">According
to a </span><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">recent</span><span style="background: white; color: black; font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span><a href="http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-us-compares-with-other-countries.html"><span style="background: white; font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">report,</span></a><span style="background: white; color: black; font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> “The U.S.
did 100 MRI tests and 265 CT tests for every 1000 people in 2010 -- more than
twice the average in other OECD countries.”<span style="mso-spacerun: yes;"> </span>The causes are </span><a href="http://www.pbs.org/newshour/rundown/2012/10/seven-factors-driving-your-health-care-costs.html"><span style="background: white; font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">multifactorial</span></a><span style="background: white; color: black; font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> but the
solutions can’t be left to presidents and policymakers alone. An important part
of the responsibility rests with healthcare professionals and the educators who
train them.<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">Experts in </span><a href="http://www.nejm.org/doi/full/10.1056/NEJMp0911502"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">health
professions education</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"> and </span><a href="http://jama.jamanetwork.com/article.aspx?articleid=1367571"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">economics</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"> have
lamented the poor state of education on healthcare costs.<span style="mso-spacerun: yes;"> </span>Over 60% of U.S. medical graduates
describe their medical economics training as </span><a href="https://www.aamc.org/download/300448/data/2012gqallschoolssummaryreport.pdf"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">“inadequate.”</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"> </span>Not only are medical trainees </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/22655140"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">unaware</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">
of the costs of the tests that they order, they are rarely positioned to
understand the downstream financial harms medical bills can have on patients.<span style="mso-spacerun: yes;"> </span>More recently, Medicare, the largest
funder of residency training in the United States, is </span><a href="http://www.medpac.gov/documents/Jul09_ResidencyPrograms_CONTRACTOR_CB.pdf"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">concerned</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">
that we are not producing the physicians to practice cost-conscious medicine in
an era of diminished resources. <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">We have been scared in the dark too long and this Halloween
the time has come to </span><a href="http://teachingvalue.org/takecharge"><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">Take Charge</span></i></a><i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">. </span></i><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">Join us now at </span><a href="http://teachingvalue.org/takecharge"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">http://teachingvalue.org/takecharge</span></a><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman"; mso-bidi-font-family: "Times New Roman";">About
Teaching Value: the Costs of Care Teaching Value Project is an initiative
of <span style="mso-field-code: "HYPERLINK \0022http\:\/\/www\.costsofcare\.org\/\0022 \\t \0022_blank\0022";"><span class="MsoHyperlink">Costs of Care</span></span> that is funded by the <span style="mso-field-code: "HYPERLINK \0022http\:\/\/www\.abimfoundation\.org\/\0022 \\t \0022_blank\0022";"><span class="MsoHyperlink">ABIM Foundation</span></span>.<span style="mso-spacerun: yes;"> </span>Our team is comprised of medical educators and trainees who
believe it is time to transform the American healthcare system by empowering
cost-conscious caregivers to deflate medical bills and protect patients'
wallets. Our web-based video modules are designed to be easy to access
for anyone anywhere and provide a starting point for tackling this problem.
It’s time to emerge from the darkness and do our part to tame the terror of
healthcare costs.<o:p></o:p></span></i></div>
<!--EndFragment-->Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com26tag:blogger.com,1999:blog-3537910058667804944.post-29791976415021602342012-10-30T10:11:00.000-04:002012-10-30T10:11:12.130-04:00Thinking through the Cost of Childbirth<span class="Apple-style-span" style="font-family: Raleway, Arial, sans-serif; font-size: 14px; line-height: 20px;"></span><br />
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<em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Dr. Lauren Demosthenes is an assistant professor of clinical ob/gyn at the University of South Carolina – Greenville.</em></div>
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I had lunch with my old college roommate last week She’s a new grandmother and was telling me about her daughter who lives in another state. Her daughter is self pay because she and her husband own a restaurant and have opted out of insurance due to the cost. She received her hospital bill in the mail and she was surprised at the cost of some of the items. As she looked through her bill, she saw some items that she wasn’t even aware that she used. In my county, 20% of our population is uninsured and these charges are important.</div>
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Well…</div>
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What if this was her scenario?</div>
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<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Doctor: </strong> Hi Mrs Kim, so glad to see you. I see that you are here to have your labor induced. Welcome to our hospital. We are going to use something to help get your cervix ready. You have 2 choices – we have something that costs $12.00 and we have something that costs $810. They work pretty similarly. I kind of like the $810.00 one, but you’re paying for it. Which one would you like?</div>
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<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Patient: </strong> Gee Dr. Greene. I think I would like the $12.00 one if it’s all the same. You see, I’m self employed and we can’t afford health insurance so we’re self pay. I would prefer to pay $12 over $810.00.</div>
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; line-height: 24px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 10px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Doctor: </strong> That’s great. I’ll see you in the morning on the labor floor.</div>
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; line-height: 24px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 10px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<em style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; font-style: italic; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Next day : </em> the Labor and Delivery goes well and a healthy baby boy is born with apgars of 9/9.</div>
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; line-height: 24px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 10px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Doctor:</strong> Now Ms. Kim, we’re going to draw a little test on your baby’s cord blood to make sure he is as healthy as he seems. His fetal heart rate looked good during labor and his apgars are great, but sometimes we just like to do things to “make sure”. It only costs $225.00 for you, but it’s a good test for us doctors to do. It just makes us feel better and it’s what we have always done here at our hospital.</div>
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; line-height: 24px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 10px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Patient: </strong> Gee, Dr. Greene, the baby is crying and looks really good. If it’s all the same to you, I’d like to pass on that. I can probably use that $225.00 to buy him diapers and food and such. But thanks for thinking of me.</div>
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<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Doctor: </strong> That’s great Mrs. Kim. Now we’re going to send you over to postpartum. You had a few stitches and we’ll have pain medicine and ice packs and some other lotions that you can use. You can ask for whatever you want. We have witch hazel pads, a nice spray lotion and some foam. The foam costs $155.00 and we use over 200 of these a month around here so I think it’s a good product. We’ll bring all of them to you. That way you’ll have all of them even if you don’t need them.</div>
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; line-height: 24px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 10px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Patient:</strong> Gee Dr. Greene, I think I’ll try some ice and advil first. I did that with my first baby and I was fine. Like I said, I have to pay for all of this myself and I really don’t want anything that I don’t really need.</div>
<div style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; font-size: 14px; line-height: 24px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 10px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<strong style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; background-position: initial initial; background-repeat: initial initial; border-bottom-width: 0px; border-color: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #1c1c1c; font-size: 14px; font-weight: bold; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">Doctor:</strong> Sure, Mrs. Kim. We’re here to provide the best care ever.</div>
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The scenario above is pretty much true – all except for the fact that we physicians do not typically know the costs of these items and we often do not consider cost when we write an order.</div>
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In Greenville County, where I live, nearly half of our residents are either uninsured or have insurance but have to postpone medical care because of cost. Most of the uninsured are employed, but many aren’t offered insurance at work, while others have access to coverage but can’t afford it.</div>
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I am working on a project to increase cost awareness among obgyn physicians. Through this project, I believe that we can identify products, services, and tests that are unnecessary, and if eliminated, will not decrease the quality of care. I know that I can do better. And maybe, just maybe, Mrs. Kim will leave the hospital with more money to spend on her baby.</div>
Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com15tag:blogger.com,1999:blog-3537910058667804944.post-69403356823967745772012-10-24T09:00:00.000-04:002012-10-24T09:00:16.419-04:00Why Residents Are Vital To Successful High-Value Education Projects<br />
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<em>Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California Sa</em><em>n Francisco (UCSF). He is currently Co-Chair of the UCSF DHM High Value Care committee. During residency training he co-created a cost awareness curriculum for residents at UCSF. </em></div>
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I learned a lot of medicine during residency, but perhaps I actually learned even more about how to just get things done in a hospital. If you wanted a right-upper-quadrant ultrasound done for our patient, I was your man. I had a complicated series of unwritten algorithmic flow diagrams in my head that included handwriting an order, making sure that it was faxed to the right number, calling the appropriate person to get a technician if it was afterhours, and knowing who to call for the preliminary results. These were all dependent on the day of the week, time of day, and whether we were at UCSF, San Francisco General Hospital, or the V.A. Sound ridiculous? Yes, it was.</div>
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Trust me, though, these broken systems are not unique to our medical center. Consider, the following analogies from the brand new <a data-mce-href="http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx" href="http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx">Institute of Medicine report</a>:</div>
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<li>“If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records.</li>
<li>If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.</li>
<li>If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.”</li>
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Yes, ridiculous, indeed.</div>
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I have been out of residency now for exactly 87 days, and everything has changed. A new <a data-mce-href="http://russcucina.wordpress.com/2012/05/31/an-epic-go-live-live-blog/" href="http://russcucina.wordpress.com/2012/05/31/an-epic-go-live-live-blog/">computer system</a> has been implemented at our hospital and a whole new crop of interns - like <a data-mce-href="http://www.themaphouse.com/SpecialistCatalogues/FerdinandMagellan.aspx" href="http://www.themaphouse.com/SpecialistCatalogues/FerdinandMagellan.aspx">Magellan chartering</a> the Atlantic to the Pacific for the first time - are boldly routing out their own new process maps for countless different scenarios.</div>
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As an attending, my new formula (thankfully) looks like this:</div>
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“Need ultrasound done -> Ask intern.”</div>
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I am already woefully out-of-touch.</div>
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My point is, if you want to know about all of the <a data-mce-href="http://www.healthcarefinancenews.com/news/8-kinds-waste-driving-healthcare-costs" href="http://www.healthcarefinancenews.com/news/8-kinds-waste-driving-healthcare-costs">waste in the system</a>, the crazy things that we do that don’t make any sense, the countless middlemen and non-value-added steps, and the <a data-mce-href="http://well.blogs.nytimes.com/2012/08/27/overtreatment-is-taking-a-harmful-toll/" href="http://well.blogs.nytimes.com/2012/08/27/overtreatment-is-taking-a-harmful-toll/">overtreatment and excess testing that lead to harm for patients</a>, then you need to ask a resident on the “frontlines.” And, you know what? Not only do they intimately know about these areas of nonsense, but it drives them the most insane!</div>
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This is because this pervasive waste in medicine is disrespectful not only to the patients that we inflict it on, but also to our medical professionals whose time is squandered maneuvering through meaningless steps.</div>
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At a recent national meeting, the question was raised by a medical educator, “But how do we try to implement “<a data-mce-href="http://choosingwisely.org" href="http://choosingwisely.org/">Choosing Wisely</a>” or “<a data-mce-href="http://www.ihi.org/knowledge/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx" href="http://www.ihi.org/knowledge/Pages/IHIWhitePapers/GoingLeaninHealthCare.aspx">Lean</a>” initiatives when we have trainees at our medical center?”</div>
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The question should not suggest how do we achieve these goals <em>despite </em>trainees, but rather how do we do this <em>with</em> trainees. No, take it even a step further. How do we get our trainees to show<em> us</em> how to best incorporate a “Choosing Wisely” philosophy?</div>
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Let’s consider this illustration. As a third year medicine resident, I was the primary “champion” for our new Cost Awareness curriculum at UCSF. Frankly, my colleagues were rooting for me to succeed. Now, the questions posed at the conferences by residents after we “<a data-mce-href="http://costsofcare.blogspot.com/2012/07/teaching-costs-of-care-opening-pandoras.html" href="http://costsofcare.blogspot.com/2012/07/teaching-costs-of-care-opening-pandoras.html">opened up Pandora’s box</a>” of cost consciousness were not necessarily easy – I don't think that many punches were pulled by some who were uncomfortable talking about hospital charges for the first time, or reviewing cases that showed our excesses. But the majority buy-in and enthusiastic support of the residents for a project by one of their own was likely a powerful strength to our successful launch.</div>
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My fellow residents stopped me in the wards to tell me “how proud” I would be of them for… talking their intern through not getting that unnecessary chest CT scan, or stopping the <a data-mce-href="http://www.aafp.org/afp/2002/0115/p309a.html" href="http://www.aafp.org/afp/2002/0115/p309a.html">repeat blood cultures within 72 hours</a> for their patient with fever, or… on it went. This curriculum and movement was something that we were doing together, not something being done to us.</div>
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So, what can departments and residency programs do to help facilitate residents’ involvement in these sorts of projects?</div>
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1. We can provide the scaffolding necessary for success. The first time I wrote up a formal educational needs assessment, or gave a noon conference, or spoke at a scientific meeting, I needed faculty mentors to help guide me through the process. With this sort of backbone support I was able to climb so much higher than I would have on my own. To help catalyze this process, programs can actively identify and match residents with appropriate mentors who are experienced in Quality Improvement and/or Value projects.</div>
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2. We can do what <a data-mce-href="http://sfgh.medicine.ucsf.edu/news/fom/frontiers.html?key=46&title=%22Choosing+Wisely%22" href="http://sfgh.medicine.ucsf.edu/news/fom/frontiers.html?key=46&title=%22Choosing+Wisely%22">Dr. Talmadge King</a>, Chair of Medicine at UCSF, did recently and explicitly state that “Choosing Wisely” is a priority of our department. This means a commitment to put some of our support, time and resources behind these types of projects and educational initiatives.</div>
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3. We can specifically carve out time for residents to pursue, achieve and present these projects during their residency. I mind you, not in spite of their patient care training, but in line with it. Many programs already do this for traditional research projects. We need to create an environment where these new types of projects are valued as academic contributions to our institutions.</div>
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4. We can help obtain and share data about costs, charges and variation at our own medical centers. For many this information is impenetrably, and unreasonably, hidden and opaque. We need help from the top to get access to this data.</div>
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5. And if all else fails, we can do what we always do in medicine to convince people that this is a worthy cause. We can quote <a data-mce-href="http://en.wikipedia.org/wiki/William_Osler" href="http://en.wikipedia.org/wiki/William_Osler">Sir William Osler</a>: “Medical care must be provided with the utmost efficiency. To do less is a disservice to those we treat, and an injustice to those we might have treated (1893).”</div>
Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com5tag:blogger.com,1999:blog-3537910058667804944.post-24788576291543827202012-09-30T09:00:00.000-04:002012-09-30T09:00:04.687-04:00More is Not Always Better<div class="separator" style="clear: both; text-align: center;">
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<span style="mso-spacerun: yes;"><em><span style="font-family: Arial, Helvetica, sans-serif;">Dr. Robert Dickman is the founding Jaharis Chair of Family Medicine at Tufts University School of Medicine</span></em></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">More than 40 years ago as a third year medical student, I recall the Chief of Medicine praising a fellow student for his rare diagnosis of paroxysmal nocturnal hemoglobinuria in a patient who had presented with the common symptom of “painless hematuria”. The lesson was not lost on any of us: good medicine means an expansive differential diagnosis and an even longer list of tests (including expensive ones) to “rule them out”. “More is better” and “being complete” while rarely explicitly stated were nevertheless at the foundation of the practice of medicine.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">I have, over these many years, constantly pushed back against this approach. While it may earn academic praise, it rarely leads to answers and often adds unncessary costs. In my own practice whether on an Indian Reservation (where few tests were available) or in an <st1:place w:st="on"><st1:placename w:st="on">Academic</st1:placename> <st1:placename w:st="on">Health</st1:placename> <st1:placetype w:st="on">Center</st1:placetype></st1:place> (where everything was) I have tried to practice efficient and cost-effective care. Whether ordering a throat culture only when indicated (rarely) or not getting yearly MRI’s on my Alzheimer patients, I was always mindful of not wasting resources. Along the way, I never felt I was compromising care.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">Over the years, I have been honored to teach countless numbers of students and residents.<span style="mso-spacerun: yes;"> </span>I have asked them questions like “how will your care change with information from this test?” or "is that the first thing you think of in a patient with these symptoms?” I have told them over and over again “time is our ally not our enemy” and “medicine is all about probabilities not possibilities. I have hoped to demonstrate on patients in the clinic or on the wards that good care is providing the highest quality at the lowest cost. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">I know I’m not alone but sometimes it really does feel like it. The misuse of resources continues unabated. Many years ago <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Dickman%20R%2C%20%E2%80%9CAlternatives%20to%20Defensive%20Medicine%E2%80%9D%2C%20Hospital%20Medical%20Staff%2C%20Dec%201982">I wrote an article decrying the routine use of skull films</a> for head trauma in ED’s. I argued that there were guidelines in place that could reduce the use of this “expensive” resource by over 50%!<span style="mso-spacerun: yes;"> </span>Today the situation is even worse. An 80 year old woman with a scalp laceration will almost definitely be “imaged” in most of our ED’s. Inpatients on a medical ward get daily labs regardless of their problems</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">We are, I think, on a collision course. Our medical arsenal continues to expand and our population continues to age. CT scans replace skull films, MRI’s replace CT’s<span style="mso-spacerun: yes;"> </span>and PET scans replace MRI’s, each considerably more expensive than it’s predecessor. Patents and providers BOTH continue to believe that more is better.<span style="mso-spacerun: yes;"> </span>Unless we are prepared to spend 50% of our GNP on health care, our present system is simply not sustainable.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">While it is not hard to define the “problem” solutions are much more challenging. We can (and<span style="mso-spacerun: yes;"> </span>have) utilize financial disincentives to alter provider and patient behavior. This has been tried off an on since the early 70’s when the HMO bill was passed (in my view one of the most progressive pieces of health care legislation in the last century). There was and continues to be a belief that such an approach is all about money. The “gatekeeper” metaphor has at its core the notion of keeping patients “away” from something. For some patients (and their lawyers) it was about cost saving trumping quality. For some (mostly on the political right) it’s about the government practicing medicine.</span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">It will, I believe, be necessary to dramatically change the nature of this conversation. The kind of medicine about which we are speaking has much more to do with value than cost. No one would buy a<span style="mso-spacerun: yes;"> </span>TV set that cost $10K more than its competitor yet performed in exactly the same way. In medicine, however, many think that the more it costs the better it is regardless of performance. Until we have a new generation of physicians and their teachers who believe in value-driven medicine (and patients who seek it out) we will never get the health care system we deserve and need. Until doctors and medical students are rewarded for logical evidence based problem solving and not test ordering we can expect health care costs to rise with no change in quality. As a result value will diminish. </span></div>
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Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com5tag:blogger.com,1999:blog-3537910058667804944.post-15931758997205142842012-09-05T06:00:00.000-04:002012-09-05T06:00:04.929-04:00Costs of Care Essay Contest 2012: Stories from Patients and their Caregivers Uncover Opportunities to Improve Healthcare Value
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<i><span style="font-family: Helvetica;">Neel Shah, MD is the Executive Director of Costs of Care and a chief resident in obstetrics and gynecology based at Harvard Medical School.</span></i></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">As a presidential election looms and the
American economy struggles to recover, the spiraling costs of healthcare have
become a contentious political focal point without an obvious solution. Yet for
patients and their caregivers, opportunities to get more bang for our buck
present themselves every day. Over the last two years, as part of the <a href="http://www.costsofcare.org/essay">Costs of Care Essay Contest</a>, we
have collected hundreds of anecdotes from all over the country that are filled
with lessons learned. <o:p></o:p></span></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">Some stories describe all too common medical
oversights. Renee Lux, a patient from Connecticut wrote to us about an <a href="http://www.marketplace.org/topics/your-money/commentary/health-care-costs-pain-neck">unnecessary
CT scan</a> her doctor should have never ordered that labeled her with a
preexisting condition and caused her insurance premiums to skyrocket. Other
stories describe easily replicated ingenuity. Molly Kantor, a third year
medical student, told us how she figured out how to treat her patient’s heart
failure on a <a href="http://costsofcare.blogspot.com/2012/01/treating-heart-failure-on-100-budget.html">$100
budget</a>. <o:p></o:p></span></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">Increasingly, these stories and the insights
they provide are striking a chord, helping drive an important professional
discourse that in recent months has reached the <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1205634">New England Journal of
Medicine</a> and even the <a href="http://www.iom.edu/Home/Global/Perspectives/2012/DemandingValue.aspx">Institute
of Medicine</a>. This effort has been buoyed by the success of the ABIM
Foundation’s <a href="http://www.choosingwisely.org/">Choosing Wisely</a>
Campaign, and several other notable <a href="http://www.abimfoundation.org/Events/2012-Forum/~/media/Files/2012-forum/key-initiatives-promote-appropriate-resource-use.ashx">initiatives</a>
aimed at getting caregivers to examine their own role in healthcare spending.<o:p></o:p></span></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">That is why this year we’re running the contest
again.<o:p></o:p></span></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">With the help of Jeffrey Drazen
(editor-in-chief, New England Journal of Medicine), Donna Shalala (former
United States Secretary of Health and Human Services), Zeke Emanuel (ethicist
and former White House healthcare advisor) and Pauline Chen (surgeon and New
York Times columnist), Costs of Care will be awarding $4000 in prizes to
stories that best illustrate the importance of cost-awareness in medicine.<o:p></o:p></span></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">All stories are
fair game and everyone is welcome to participate - examples may include a time
a patient tried to find out what a test or treatment would cost but was unable
to do so, a time that caring for a patient generated an unexpectedly a high
medical bill, or a time a patient and care provider figured out a way to save
money while still delivering high-value care. Submissions are due to <a href="mailto:contest@costsofcare.org">contest@costsofcare.org</a> no later than
November 15, 2012.<o:p></o:p></span></div>
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<span style="font-family: Helvetica; mso-bidi-font-family: Helvetica;">Ultimately, no
amount of regulating, reorganizing, or otherwise reforming the healthcare
system will successfully contain costs unless we—both patients and providers--are
invested in fixing the problem.</span></div>
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<!--EndFragment-->Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com18tag:blogger.com,1999:blog-3537910058667804944.post-56356652742259517742012-08-27T08:00:00.000-04:002012-08-27T13:31:18.076-04:00Video Webinars: Educating the Whole Community About Healthcare Cost Control<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyQwWXDLt98aN8-_gV1R_LOfshJ1Ox8H5uWUUVZ4azY_xkwmwRetf8WBjmeYsbSpKQ7-22gXfMVEN6pIrUJi0n23kI3aXXbzc0j8t31W2GN9LfZhqFuu_bH2h1dTX9gWFS12CyUDLZC7k/s1600/Morse+Headshot.jpg" imageanchor="1" style="clear: left; cssfloat: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhyQwWXDLt98aN8-_gV1R_LOfshJ1Ox8H5uWUUVZ4azY_xkwmwRetf8WBjmeYsbSpKQ7-22gXfMVEN6pIrUJi0n23kI3aXXbzc0j8t31W2GN9LfZhqFuu_bH2h1dTX9gWFS12CyUDLZC7k/s1600/Morse+Headshot.jpg" yda="true" /></a></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: x-small;"><em><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">Abraham (Nick) Morse MD, MBA is currently Assistant Professor of Obstetrics and Gynecology at Harvard Medical School</span></em><br />
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</span>This year has been a busy one for the issue of cost-containment in health care. When I am not caring for women with incontinence and prolapse, I am often engaged with friends, family and other health care stakeholders trying to describe and illuminate the hugely frustrating, inefficient, and misaligned relationship between delivering health care and how we pay for it. The voices of consumers and physicians have been somewhat muted in the conversations that surround the development of government policy designed to reform a system that almost everyone agrees is very broken – even if we don’t agree on how to fix it. The causes and effects are complex and the solutions nuanced. As in many areas of public policy, it is easy to scare your target audience with sound bites (e.g. “Death Panel”) and much harder to capture the salient issues for those who need to gain a balanced view of the fundamental forces that affect how health care is delivered and paid for in this country – which is all of us. </span><span style="font-family: Arial, Helvetica, sans-serif;"></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">To try and bridge this gap and with the help of funding from the Robert Wood Johnson Foundation, two respected organizations in Boston - The Greater Boston Interfaith Organization (GBIO), and Tufts Health Care Institute (THCI) - are jointly organizing and presenting a series of educational webinars for consumers on health care cost containment. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">In the spirit of full disclosure, I volunteer for GBIO in the role of physician advisor to the Health Care Team. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">This series of webinars (7 are planned) will address health care cost containment, provider payment reform, and related issues. The overall goal is to educate consumers about the health care system and strategies for improvement so that consumers can develop an informed voice and participate confidently in discussions of health care cost control with public and private stakeholders. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Each webinar is presented as a live online event, which is recorded and archived. The webinars feature an audio presentation by the faculty, accompanied by slides. Reference materials related to each webinar are also available for download. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Both can be found on the THCI/GBIO web pages at:</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://thci.org/GBIO/welcome.aspx">http://thci.org/GBIO/welcome.aspx</a></span><br />
<br />Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com2tag:blogger.com,1999:blog-3537910058667804944.post-76565220130548489452012-07-27T05:32:00.002-04:002012-07-27T05:32:50.850-04:00Teaching Costs of Care: Opening Pandora's Box<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhPGIWCb2J5n-IlLLtBk6oJVgHF4KaPgocMuSgPMTNn8bIwh-3fWzvfaNfPWB-2i9QgALIzERhBBiWNcg0jis9Zi8fx3CnBRcpV57jvdiCGL_vT_l2iuQa3IHHTfbGahnV5suh1SuI2Nw/s1600/Dr.+Vineet+Arora+Picture_high+res.jpg" imageanchor="1" style="clear: left; cssfloat: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" sda="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhPGIWCb2J5n-IlLLtBk6oJVgHF4KaPgocMuSgPMTNn8bIwh-3fWzvfaNfPWB-2i9QgALIzERhBBiWNcg0jis9Zi8fx3CnBRcpV57jvdiCGL_vT_l2iuQa3IHHTfbGahnV5suh1SuI2Nw/s200/Dr.+Vineet+Arora+Picture_high+res.jpg" width="151" /></a></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><em>Dr. Arora is an associate professor of medicine and Assistant Dean for Scholarship and Discovery<br />at the University of Chicago Pritzker School of Medicine</em></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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 <a href="http://www.acponline.org/education_recertification/education/curriculum/">High Value Cost Conscious Curriculum</a> for what has now been dubbed the “<a href="http://www.ama-assn.org/ama/pub/amawire/2011-september-28/2011-september-28-rfs.shtml">7th competency</a>” 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 <a href="http://www.costsofcare.org/">Costs of Care</a> to use video vignettes to illustrate teaching points to physicians in training about costs of care called the <a href="http://www.abimfoundation.org/News/ABIM-Foundation-News/2012/Costs-of-Care.aspx">Teaching Value Project</a>. With funding by the <a href="http://www.abimfoundation.org/">ABIM Foundation</a> , we have beenable to develop and pilot a video vignette that that depicts the <a href="http://www.kevinmd.com/blog/2010/09/10-reasons-doctors-overorder-tests.html">main reasons why physicians overuse tests</a>. 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.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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 <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266679/">higher malpractice premiums have more spending on care</a>. 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 <a href="http://economix.blogs.nytimes.com/2011/08/17/malpractice-anxiety/">worries about malpractice</a> vary little across states, even though malpractice laws vary by state.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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?”</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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?</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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) “<a href="http://www.dartmouth.edu/~cecs/hcild/hcild.html">Every system is perfectly designed to achieve the results it gets</a>.” Therefore, understanding what characteristics of systems promote cost conscious care is a critical step.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">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 <a href="http://en.wikipedia.org/wiki/Robert_M._Gagn%C3%A9#Nine_Steps_of_Instruction">Robert Gagne</a>, 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 <a href="http://www.abimfoundation.org/News/ABIM-Foundation-News/2012/Costs-of-Care.aspx">Teaching Value Project</a>. So while learning why tests are overused is a first step… judging by Pandora’s box, it is certainly not the last.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">--Vineet Arora MD MAPP</span>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com3tag:blogger.com,1999:blog-3537910058667804944.post-59420755554915355962012-07-23T06:00:00.000-04:002012-07-23T06:00:01.422-04:00“Go Ask Your Doctor…” – Educating Patients and Physicians About Costs of Care<br />
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<i><span style="color: #262626; font-family: Arial;">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) </span></i><i><span style="color: #262626; font-family: Arial;">High-Value, Cost-Conscious Care Curriculum Development
Committee. <span class="Apple-style-span" style="font-size: 13pt;"><o:p></o:p></span></span></i></div>
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The New York Times said that I probably should <a href="http://www.nytimes.com/2012/06/03/sunday-review/lets-not-get-physicals.html?_r=1">skip
my annual physical</a>. The other day, Consumer Reports sent me something in
the mail entitled, “<a href="http://www.consumerreports.org/content/dam/cro/news_articles/health/PDFs/High_Value_Care_Back_Pain.pdf">Imaging
tests for lower-back pain: Why you probably don’t need them</a>.” 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 “<a href="http://www.consumerreports.org/cro/magazine/2012/06/many-common-medical-tests-and-treatments-are-unnecessary/index.htm">Learn
when to say ‘Whoa!’ to your doctor</a>.” The ABIM Foundation’s widely
publicized <a href="http://www.choosingwisely.org/">“Choosing Wisely” campaign</a>
popularizes lists of various practices that “physicians and patients should
question.” </div>
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Instead of “Go <a href="http://www.youtube.com/watch?v=KDarqCVXUoQ">ask your doctor</a> 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 <a href="http://costsofcare.org/about-costs-of-care/our-team">not the only one</a>.</div>
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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 <a href="http://www.bloomberg.com/news/2011-07-12/medicine-s-big-mystery-what-does-treatment-cost-mimi-ferraro.html">illustration
of the doctor taking a stab in the dark</a> is just about right). </div>
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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 <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1205634">brand new, balanced
article in the New England Journal of Medicine</a>, 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.</div>
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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. </div>
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I will reappropriate an analogy that <a href="http://community.the-hospitalist.org/">Bob Wachter</a>, 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.”</div>
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Ente<a href="http://www.blogger.com/blogger.g?blogID=3537910058667804944" name="_GoBack"></a>r the new <a href="http://annals.org/article.aspx?articleid=1215792">AAIM-ACP High-Value,
Cost-Conscious Care curriculum</a>, 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 <a href="http://www.highvaluecarecurriculum.org/">www.highvaluecarecurriculum.org</a>.
</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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 <a href="http://www.acponline.org/education_recertification/education/curriculum/hvccc_curriculum_overview.pdf">overview
of this curriculum</a> 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. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I encourage you to go <a href="http://www.highvaluecarecurriculum.org/">check it out</a>.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Go ask your Program Director or Chief Resident if the high
value care curriculum is right for you. </div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com5tag:blogger.com,1999:blog-3537910058667804944.post-88613830861848231212012-07-09T06:00:00.000-04:002012-07-09T06:00:08.764-04:00Surgery at $147 per minute<!--[if gte mso 9]><xml>
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<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFyM9nW9DrJNLMkyavL1obg53kDMO6B7xPmXJlq_ssnkscyDX3emrCcCEsXorgqFKuypR99bGBg0nvEzu4XFSzB6PGueXnuYVMTL1q_5MCBhA0YCHdhQRqyY4y10j5COhEls3Uh5LnTFk/s1600/Nate+Johnson.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFyM9nW9DrJNLMkyavL1obg53kDMO6B7xPmXJlq_ssnkscyDX3emrCcCEsXorgqFKuypR99bGBg0nvEzu4XFSzB6PGueXnuYVMTL1q_5MCBhA0YCHdhQRqyY4y10j5COhEls3Uh5LnTFk/s1600/Nate+Johnson.jpg" /></a></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><i>Nate Johnson is a medical student at Tufts University and Maine Medical Center</i></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;"><span class="Apple-style-span" style="border-collapse: collapse; color: #222222; font-family: arial, sans-serif; font-size: 13px;"><i><br /></i></span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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. </span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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. </span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">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.</span></div>
<!--EndFragment-->Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com6tag:blogger.com,1999:blog-3537910058667804944.post-15817261939884295832012-06-25T07:00:00.000-04:002012-06-25T07:00:00.898-04:00Medical Students Write Handbook for their Peers<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0MTojUWZc51LGaLd6UDenBy2-iJ0nvGYnbHnvf6xSiIVvJesfovSwqwdg8V8Wg6GXC1ZJ59Y_pX1sK33j2SfvzZ_ptuNnWM0w44dbBprsYDPZODfLyhFVibqU34oivrKYMmbNBJxv34U/s1600/askin+headshot.jpg" imageanchor="1" style="clear: left; cssfloat: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" rca="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0MTojUWZc51LGaLd6UDenBy2-iJ0nvGYnbHnvf6xSiIVvJesfovSwqwdg8V8Wg6GXC1ZJ59Y_pX1sK33j2SfvzZ_ptuNnWM0w44dbBprsYDPZODfLyhFVibqU34oivrKYMmbNBJxv34U/s200/askin+headshot.jpg" width="128" /></a></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-family: Calibri; mso-ansi-language: EN-US; mso-bidi-font-family: "Times New Roman"; mso-bidi-language: AR-SA; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-US;"><em>Elisabeth Askin is a third year medical student at Washington University in St Louis and co-author of <a href="http://www.healthcarehandbook.com/">The Health Care Handbook</a> for medical students.</em></span></span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">In 2008, I volunteered at the San Francisco General Hospital Emergency Room, enrolling patients in research studies. One study correlated clinical signs in trauma patients with positive findings on chest x-rays, so that orders could be better informed and more efficient. And efficiency was certainly needed - I was stunned to learn that only 3% of trauma chest x-rays yield positive results. That’s a lot of time, money, and energy for very little useful information.</span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">We may not doubt the judgment of those ER physicians, but we also know that each clinical decision has an effect on the national bottom line. Health care costs in the U.S. have reached 17% of GDP and continue to rise. Everyone agrees that our current situation is unsustainable and that change is necessary. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Cost is not the only way that the individual, daily behavior of providers and patients combine to form a larger picture. Obvious examples include rising antibiotic resistance and defensive medicine. Less obvious examples include off-label prescribing and the obesity epidemic. Whether we recognize it or not, all of our actions are affected by – and in turn affect – larger societal trends.</span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Thus, the question is: how do we combine doing what is best for each patient with understanding our role in the larger picture?</span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">For one thing, we need to have an idea of what that larger picture is. Medical students not only don’t know about prices – they often aren’t familiar with the most basic aspects of health care delivery, policy, insurance, economics, drugs & devices, or reform. It’s not because of a lack of interest but rather because getting a view of the larger picture isn’t easy. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">The news and blogs provide a ton of details without the scaffolding to connect them. Popular books often provide one-sided arguments. And scholarly books mostly offer highly detailed knowledge about solitary aspects of the system – which may obscure the forest in favor of a leaf. Meanwhile, schools usually only expect us to know that Medicare covers the old while Medicaid covers the poor. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Students shouldn’t have to work hard to cobble together an understanding of what an HMO is, how an NP differs from an RN, or what the options are for the uninsured. While trying to learn these things on my own, I found myself wishing for a dummies’ guide or a single reference, but to no avail. So a fellow medical student, Nathan Moore, and I decided to write our own. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">The Health Care Handbook: A Clear and Concise Guide to the U.S. Health Care System introduces the key facts and foundations that make the health care system work. The book includes balanced analyses of current challenges and controversies in health care, including medical errors, government regulation, medical malpractice, high drug prices, and much more. And, no surprise to anyone reading this site, we devoted an entire chapter to insurance and economics. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Medical students, residents, and attendings should know how much a chest x-ray in the ER costs, but that’s not all. They should also know how few trauma chest x-rays show any findings, how little care in the ER gets reimbursed, that hospitals are building new cardiology wards to offset those costs, and what kind of testing the new devices in the cardiology wards have to go through. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">We need to make sure that our behavior, while always determined by the patient in front of us, rationally and practically acknowledges the system in which we work. Those of us in medical school now know this will play larger role in our careers than it ever has before. It’s time to start asking for more education about it.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com45tag:blogger.com,1999:blog-3537910058667804944.post-38597666858942149442012-06-18T08:00:00.000-04:002012-06-18T08:00:13.252-04:00The New Generation of Medical Students<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-IDcGwo9EGb88UxcAodbzzZniMTbB1N28MJHlLAnJYkTVdWJprRHA7pj6miWtSPI4_8Xuv0yOhFMrDTdKv3Ndft9pOFqtVKuWRQtQ10rAoklHdklNMweVMhlSkmzdifEcznvKTsBli_4/s1600/Ioana.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-IDcGwo9EGb88UxcAodbzzZniMTbB1N28MJHlLAnJYkTVdWJprRHA7pj6miWtSPI4_8Xuv0yOhFMrDTdKv3Ndft9pOFqtVKuWRQtQ10rAoklHdklNMweVMhlSkmzdifEcznvKTsBli_4/s200/Ioana.jpg" width="144" /></a></div>
<i>The following post is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard</i><br />
<i><br /></i><br />
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
We are a new
generation of physicians and physicians in training. The words “stem cell therapy”, “Robertsonian translocation”
and “artificial tracheal transplant” were part of our vocabulary from the first
day of medical school. At the
astounding speed at which scientific advancements are made, our ability to
incorporate new material is in a constant state of change. Slowly, the heavy textbooks became
relics, as we migrated towards a mobile knowledge, a way for us to carry around
and receive up to date medical information at any time or place of the day. We became the generation of iPhones and
iPads, the generation who is satisfied with the ability “know where and how to
find the information”, painfully aware of our inability to memorize and keep up
with everything.</div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
But in spite of
the growing fluidity of the medical curriculum, it was baffling for most of us
to enter the “real world” of hospitals and clinics and realize how little we
knew. While we were quite familiar
with the Krebs cycle, electrolyte imbalances, rare genetic mutations, the
“high-tech” seemingly comprehensive medical school curriculum stopped short. During
our clinical years, we realized that our knowledge of pathophysiology was
dwarfed by our unawareness of the issues that are so saliently engrained in the
lives of our patients. Not a
single medical student knew what a complete blood count test would cost, or how
much a patient would be billed after a night in the intensive care unit. Yet,
we took pride in knowing how to enter an order in the computer and interpret an
abnormal test. We were naïve to
think that our patients are “non-adherent” to medications, when in reality,
they just couldn’t afford them and were too embarrassed to admit it. These issues were foreign to us. </div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
The definition
of a “good physician” has changed in the last few years. It is no longer sufficient to limit
ourselves to medicine; we <i style="mso-bidi-font-style: normal;">must</i> learn
to take a holistic approach towards helping our patients, and this includes a
keen awareness that our best medical care could mean their bankruptcy. In the last few years, physicians
started to recognize “pain” as a 5<sup>th</sup> vital sign, in addition to
temperature, heart rate, respiratory rate and blood pressure. Perhaps it is time to consider “ability
to pay for medical expenses” as a close-up runner to our list of vital signs,
one that could easily increase your heart rate and make one short of
breath. </div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
We are a new
generation of physicians and physicians in training. And our vocabulary ought to include words like
“cost-awareness”, “cost-efficiency”, and “cost-reduction”. At the astounding speed at which medical
costs are increasing, our minds are thirsty for more knowledge, more skills and
more wisdom at how to truly become a physician of the 21<sup>st</sup> century.</div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com9tag:blogger.com,1999:blog-3537910058667804944.post-71382094586264998092012-06-11T06:00:00.000-04:002012-06-11T06:00:01.332-04:00A recommendation to minimize costs backfires<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrHdDh2QEoTTNACHzQIW8tBtFa4EJd5cz7lJT6GpECbLSkXioOO05v-kQw7qBWTX9OTaiIVcjvZRSfFkm33DGylJKDDIhC5NwRtO90kSxF_6Yq6n32o2pz5fG-7ZEES8FQqNkAgkbVVdc/s1600/doctor-patient-bed.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" fba="true" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjrHdDh2QEoTTNACHzQIW8tBtFa4EJd5cz7lJT6GpECbLSkXioOO05v-kQw7qBWTX9OTaiIVcjvZRSfFkm33DGylJKDDIhC5NwRtO90kSxF_6Yq6n32o2pz5fG-7ZEES8FQqNkAgkbVVdc/s320/doctor-patient-bed.jpg" width="320" /></a></div>
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><em>The following anecdote is by Alexis Ball, the daughter of a patient from New Mexico. Her story was originally submitted to the <a href="http://www.costsofcare.org/essay">2011 Costs of Care Essay Contest</a>.</em></span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">My mom passed away last December to Stage V breast cancer metastasized to her liver. During this battle she developed ascites (an accumulation of fluid in the peritoneal cavity) as her liver failure progressed. This accumulation of fluid was not only extremely uncomfortable but painful as well. In an attempt to find symptomatic relief for the last months of my mom’s life, the oncologist presented us two options: we could come in to clinic weekly and be tapped to have the fluid drained or we could implement a permanent drain in her peritoneal space. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Per the doctor’s advice, we opted for the latter option. The doctor recommended this option because my mom was on blood thinners and this plan obviated the need to continually reverse her Coumadin dose. Thus this equated to less time for her in the clinic and was less expensive for the hospital and our family… or so we all thought. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Our insurance company approved the top of the line specialty drain for this procedure. After the procedure, the hospital provided us with the first batch of drainage supplies. My dad and I learned how to properly drain my mother and change her dressings. We got into a routine of draining every night before bed. There was a dramatic improvement in my mother’s quality of life due to the release of extra of pressure in her abdomen. All was copasetic until it came time to reorder our supplies,</span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">“<em>Hello Ms. Ball! I understand that you are reordering the drainage and dressing kits , <strong>unfortunately they are out of plan for your insurance</strong></em>” </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">We were dumbfounded. How could the insurance cover a system in which they did not support the supplies? </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;"><em>“These are non durable goods and not covered. The cost of the kit will be 600 hundred dollars monthly with a deductible of 750 for the first month” </em></span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Our jaws dropped. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Due to my mother’s illness she was no longer working and was waiting to receive disability benefits. Six hundred dollars a month was more than a third of her entire income on disability. Our oncologist was horrified to learn that the nondurable goods associated with the drain were not covered. He had no idea that this was the case. Our doctor had recommended this plan to not only reduce chances of infection but also minimize costs for our family. This knowledge would have altered his recommendation of treatment plan for our family. </span><br />
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">Yet it gets better, the drainage system leaked, requiring dressing changes two to three times a day. These extra dressing changes increased our out of pocket expenses by two fold. The cost of maintaining this system was extremely prohibitive. We could either afford to pay our bills or pay for the supplies of this drainage system. Thus, we resorted to using non sterile dressings instead of the prescribed dressings. Our replacement dressings included sanitary pads, urinary pads, saran wrap, and the occasional paper towel. Although these means were clever and much more cost friendly for us, they greatly increased my mom’s chances of a peritoneal infection. A peritoneal infection would have resulted in a hospital stay and a much more costly bill for both our family and the insurance company than the sterile dressings my mom needed. My mom always joked that the solution to our financial struggles with medical care costs was for her to just hurry up and die… which much to a young daughter’s dismay was the heartbreaking truth of our situation. </span><br />
<br />Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com4tag:blogger.com,1999:blog-3537910058667804944.post-5090568738398877222012-05-21T06:00:00.000-04:002012-05-21T06:00:04.310-04:00Skipping the Daily Blood Draw<br />
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-IDcGwo9EGb88UxcAodbzzZniMTbB1N28MJHlLAnJYkTVdWJprRHA7pj6miWtSPI4_8Xuv0yOhFMrDTdKv3Ndft9pOFqtVKuWRQtQ10rAoklHdklNMweVMhlSkmzdifEcznvKTsBli_4/s1600/Ioana.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-IDcGwo9EGb88UxcAodbzzZniMTbB1N28MJHlLAnJYkTVdWJprRHA7pj6miWtSPI4_8Xuv0yOhFMrDTdKv3Ndft9pOFqtVKuWRQtQ10rAoklHdklNMweVMhlSkmzdifEcznvKTsBli_4/s200/Ioana.jpg" width="144" /></a></div>
<i><br /></i><br />
<i><br /></i><br />
<i>The following anecdote is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard University</i><br />
<br />
<br />
<br />
<br />
<br />
One of the most
memorable discussions regarding the cost of care was at 4:45AM during surgical
morning rounds. As usual, the
interns would present the overnight events of their patients to the chief
resident and a plan for the day would be agreed upon. These morning rounds were particularly intense: in addition
to the 30 patients that an intern had to manage solo over night, the brutal
hours that the surgical oncology service demanded, our chief resident, Dr. W.,
was a former army officer and his team was therefore ran in the most organized
fashion that one could hope for.
On the first morning, as the interns were plowing through test results
from laboratory data, Dr. W. asked them to justify some of the lab tests. “Why did we order a Calcium on Mr. Z.?
“, “Why do are we getting daily coagulation studies on Ms. S.?”. Everyone seemed puzzled, as this was
the first time when they were confronted with this issue. Doing daily blood draws is considered
as much of a routine as feeding patients and it seemed inconceivable that a
blood test would be skipped. Indeed, this practice has become such a habit that
nobody questioning anymore.</div>
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<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
Dr. W., with the
firmness of a longtime army veteran and the boldness of a surgeon, looked his
interns in the eye, slowly, one by one.
And as everybody’s heart was racing, he referenced a study done at the
Harvard School of Public Health a few years prior, illustrating the lack of
utility of most blood tests for hospitalized patients. Indeed, not only was drawing five tubes
of blood on a daily basis a physiologically unnecessary stress on a
post-surgical patient, but the costs associated with these tests or their
results were not justifiable. Quite
the contrary, many of these results would lead to unwarranted attempts to
correct an imbalance that did not affect the patient’s outcome. One famous phrase
in Intensive Care Units is that patients die with perfectly normal levels of
electrolytes; in other words, our fervent desire to measure everything and
balance every electrolyte is often futile.</div>
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<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
The following
morning, Dr. W. was surprised to see that once again, every patient had a
complete panel of blood test. To
their despair, the interns impatiently searched their orders just to realize
that the blood tests had been performed in the absence of physician’s orders. So deep was the custom of collecting
blood and doing daily tests, that everyone assumed it to be a routine. As we continued to round, Dr. W. would
occasionally point to the cost of a blood test, painfully emphasizing the
excessive and worthless money spending of our team. Perhaps it was the fear of missing a small detail, or the
need to be perfectionists and thorough to unreasonable limits; or perhaps it
was just our naïveté as medical students and interns to the culture of medicine
and the assumptions that we automatically accept as part of the “usual practice.”</div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-align: justify; text-indent: .5in;">
It took more
than a week for the interns to talk to each nurse, phlebotomist or lab
assistant about not performing the blood draws without explicit orders It was not an easy battle, and the
interns had to take over the responsibility of convincing the staff one by one
that while the harm of a simple blood draw is fairly minimal, the impact that
extra 30 blood draws have each day on each team’s patients in the entire
hospital is immense. Empowered by
the knowledge and the passion that Dr. W. inspired into all of them, the
interns began a slow but effective fight against unnecessary blood draws. And as a domino effect, only a few days
later, other residents had engaged in the argument and convinced their fellow
surgeons of their cause.<br />
<br />
While Dr. W.’s fight
was against a simple blood draw, his emotional determination to make a change in
the cost of health care, and more importantly in the education of brand new
residents, made him a champion. He
proved that big changes can be made on a small scale and that it is not always
the $5,000 MRI test that will crush our budget, but the trivial daily tests
that add up to hundreds of MRI costs.
He showed us how one person can change a team, a mentality, a
culture. And that it is through
small acts that great deeds can indeed be accomplished.</div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com7tag:blogger.com,1999:blog-3537910058667804944.post-53746014751296544552012-05-14T09:38:00.000-04:002012-05-14T09:38:32.795-04:00Waiting for Discharge...<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBHA3gvqUdnQKVM6fGbOxBq5uaqaTUl-6Wi2JLDxLj-mHlKrqktbnHCeeXxaAnGQtas2hStz5Pf8TZRdympC_qzllftcunEP3MT0VQ80Qul8PBKNE99PXL3SFEkZlpIKUEyZ2vu_w0hxo/s1600/kellydonovanpic.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBHA3gvqUdnQKVM6fGbOxBq5uaqaTUl-6Wi2JLDxLj-mHlKrqktbnHCeeXxaAnGQtas2hStz5Pf8TZRdympC_qzllftcunEP3MT0VQ80Qul8PBKNE99PXL3SFEkZlpIKUEyZ2vu_w0hxo/s200/kellydonovanpic.jpg" width="150" /></a></div>
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<span class="Apple-style-span" style="font-family: Arial;"><i>The following anecdote was written by Kelly Donovan, a third year medical student at Chicago College of Osteopathic Medicine</i></span></div>
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<span class="Apple-style-span" style="font-family: Arial;"><i><br /></i></span></div>
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<span style="font-family: Arial;">On a late afternoon in
mid-July I was finishing up my first Sunday on call as a third year medical
student. I glanced over the patient list for 4 East, the internal medicine
floor I had been assigned to cover. Familiar with patients in their eighties
and nineties, I was surprised to see a 22-year-old patient admitted with acute
kidney injury. </span></div>
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<span style="font-family: Arial;"><br /></span></div>
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<span style="font-family: Arial;">He was a nice-looking young man in good spirits. Spanish
was his first language, but he could converse pleasantly in English, stating
that he felt “good.” I palpated his abdomen and listened to his
heart and lungs. He reminded me of my own 21-year-old brother, and I could
easily imagine him throwing back some beers with friends or tossing around a
football. He worked for a roofing company and had been subject to the
sweltering Chicago heat for the last six days. The emergency department had
surmised that his acute kidney injury was caused by severe dehydration. My
internal medicine residents agreed and we began loading him with fluids. This
was day two of Garcia’s hospital stay. <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0in; mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Arial;">On Monday morning,
Garcia continued to deny any complaints. His blood pressure was high at
150/80, despite treatment with medications. Creatinine, a marker of
kidney function, continued to be abnormally elevated at 4.1. Ultrasound imaging showed
evidence of a complex cystic mass in the kidney, along with areas indicative of
chronic kidney disease. Multiple test results were
pending to figure out the cause, including a comprehensive immunology panel. The nephrologists consulting on his case recommended a kidney biopsy, and a follow-up ultrasound and CT scan, finding
Garcia’s previous imaging results inconclusive.<o:p></o:p></span></div>
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<span style="font-family: Arial;"> </span><span style="font-family: Arial;"><o:p></o:p></span></div>
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<span style="font-family: Arial;">On hospital day four,
Garcia’s blood pressure remained elevated with kidney function stable but poor.
On day five, the nephrologists ordered vein mapping in case the need arose for
hemodialysis. The team suspected chronic kidney disease secondary to nephrotic
syndrome; a biopsy would confirm this diagnosis. Day six was a lot like day
five, except someone checked the urine for protein. At 6.5 grams per 24 hours,
Garcia had nephrotic range proteinuria. This is when I found out that Garcia
was a self-pay patient and thus unable to afford a biopsy. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Arial;">The case manager
suggested we discharge home and recommend he follow up at the county hospital.
Unfortunately, County doesn’t take transfers. So, Garcia would have to start at
the beginning by seeing a primary care doctor during clinic, and be referred to
a nephrologist on staff. While this would save Garcia significant money, the
case manager worried about losing track of him. Despite his worrisome blood
pressure and lab values, he felt great. Daily, he denied any complaints and
smiled pleasantly throughout physical exams. <o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Arial;">Days 7, 8 and 9
followed. Garcia’s blood pressure gradually normalized, but his kidney function
remained very poor. The medicine we originally used to treat his
proteinuria caused elevated potassium and uric acid, so we had to discontinue it. His hemoglobin dropped, either due to the kidney disease,
or because we were loading him with IV fluids. It wasn't clear if our interventions were helping or hurting. So, we just watched him for three days while waiting for Nephro to sign off on the case so he could
be discharged.<o:p></o:p></span></div>
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<br /></div>
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<span style="font-family: Arial;">On day 10, Garcia’s bed
was empty. The case manager shared that he had finally been discharged. The
immunology workup still pending, they promised to alert him to the results when
available. He was instructed to look into programs that would help pay the cost
of dialysis. <o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial;">During Garcia’s hospital stay, he received
competent medical treatment. However, patient care was lacking. The failure of
communication lead to an excessive hospital stay and thousands of dollars the
patient clearly could not afford. There did not appear to be an open line of
communication between the primary doctor, the nephrologists, the case manager
and the patient’s family. By day three, the patient was stable. Why did he stay
an additional six nights in a hospital bed he could not afford? There was no
need to observe the patient while waiting for the immunology panel that
typically takes 2-3 weeks to process. Did the physicians not know he was a self-pay
patient? If aware, would it have changed their treatment plan? Perhaps the
nephrologists wanted to “solve” this unusual case. Why did it take them so many
days to sign off on the patient? And, given the language barrier, did Garcia’s
family understand the suspected diagnosis and prognosis? With better
communication, these obstacles to cost-awareness could have been avoided and
improved Garcia’s outcome.</span></div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com4tag:blogger.com,1999:blog-3537910058667804944.post-60743840831505087162012-05-07T08:00:00.000-04:002012-05-07T08:00:07.460-04:00Side Effects May Include Financial Ruin<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiI6FDCVaInE5YABUSLyPTvShLj6dBayUCNtvEEqajEjNQzF8bdLa8n5_Ni4-hxa4lllLC8qeL_5LwDuCMYnurSeFTv5JWUg18OtzPoJH5a_s1vBLrijes8aBX5tgbkG_Cl7MZtJC-gvI4/s1600/ChrisMoriartes.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiI6FDCVaInE5YABUSLyPTvShLj6dBayUCNtvEEqajEjNQzF8bdLa8n5_Ni4-hxa4lllLC8qeL_5LwDuCMYnurSeFTv5JWUg18OtzPoJH5a_s1vBLrijes8aBX5tgbkG_Cl7MZtJC-gvI4/s1600/ChrisMoriartes.jpg" style="cursor: move;" /></a><i><span style="color: #333333; font-family: Arial; font-size: 10pt;">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. </span></i></div>
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<div class="MsoNormal" style="text-indent: .5in;">
He winced in a way that made me
feel his discomfort. It wasn’t overly dramatic; it was a response of a man
trying to put on a brave face and hide his pain, but - as I gently laid my
hands on his belly - failing against his best efforts. This man had real
abdominal pain, the kind that is impossible not to immediately empathize with.
I got concerned. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
“How long has this been going on?”
I asked, while my mind began to immediately tick through a differential
diagnosis.</div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
“Well it probably started a year
ago, but got really bad about four months ago,” this otherwise
healthy-appearing, thirty-something-year-old man said. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
We were in a small curtained-off
area in the hectic Emergency Department at San Francisco General Hospital
(SFGH). I started to wonder what in the world would possibly cause somebody to
wait many months with severe abdominal pain and rectal bleeding before coming
to see a doctor. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
I asked a few more questions,
verifying that he was indeed having bright red blood with his bowel movements,
had lost at least 10-pounds over the last few months and has dealt with nausea
and debilitating abdominal pain ever since the end of last year. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
So, I pulled out one of my most
tried-and-true questions that I have picked up during residency: </div>
<div class="MsoNormal" style="text-indent: .5in;">
“What made you come to the hospital
today as opposed to yesterday or last week?” </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
The answer should have surprised
me.</div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
“Well, I didn’t want to see a
doctor because I couldn’t pay for it. I had to wait until my benefits kicked in
so that I had insurance.” </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
The Emergency Department had
already put him through the CT scanner prior to calling me to admit him to the
hospital, in order to ensure that he “didn’t have something really bad going
on,” which I have to admit that if you had put your hands on his abdomen you
would probably think was a more reasonable (if not very eloquently phrased)
concern.<span style="mso-spacerun: yes;"> </span></div>
<div class="MsoNormal" style="text-indent: .5in;">
<span style="mso-spacerun: yes;"><br /></span></div>
<div class="MsoNormal" style="text-indent: .5in;">
The CT scan showed inflammation of
his colon in a pattern that the radiologist said was very likely <a href="http://www.ccfa.org/info/about/crohns">Crohn’s Disease</a>. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
His lab tests returned with severe
anemia (hemoglobin of less than seven) and an undetectable iron level,
revealing that the bleeding had been going on for a long time. I told him that
I thought he needed a blood transfusion and a colonoscopy procedure in the
morning by one of our gastroenterologists. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
Then he asked me one of my most
feared questions that I have picked up during residency:</div>
<div class="MsoNormal" style="text-indent: .5in;">
“But how much will that all cost
and will my insurance pay for it?”</div>
<div class="MsoNormal" style="text-indent: .5in;">
“I wish that I could answer that
for you, but I really don’t know.” </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
Now, the thing is that <a href="http://blog.abimfoundation.org/where-oh-where-do-physicians-learn-about-cost-effectiveness/">I
actually have spent more than the past year working on cost awareness for
residents</a> and looking into issues related to costs of care, and even <i style="mso-bidi-font-style: normal;">I</i> couldn’t answer this question in a
straightforward and truthful manner. This man needed these things done and
costs be damned. Sure, but let’s be honest, his concern is very real. <a href="http://content.healthaffairs.org/content/early/2005/02/02/hlthaff.w5.63.short">Medical
bills are the leading cause for personal bankruptcy in the United States</a>.
And at his young age, the effects of an expensive inpatient work-up could be
devastating for a long time to come. Incredibly, in 2007, <a href="http://www.businessweek.com/bwdaily/dnflash/content/jun2009/db2009064_666715.htm">78%
of filers of personal bankruptcy caused by medical problems had medical
insurance at the start of their illness</a>.</div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
The best I was able to do was tell
him that in my medical opinion he needed these procedures in order to make the
diagnosis and get the right treatment for his disease. My medical training has
taught me how to recognize inflammatory bowel disease, diagnose it and treat
it, but it has <a href="http://www.annals.org/content/155/6/386.abstract">not
adequately addressed</a> how to not inflict insurmountable financial harm on
some of my patients in the process. To me, it is straightforward; this man <i style="mso-bidi-font-style: normal;">needs</i> medical treatment for Crohn’s
Disease. To him though I may be replacing his abdominal pain with another
debilitating problem. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
This all seems especially unfair
when just a few weeks ago we reviewed a case in our monthly UCSF Cost Awareness
conference of an elderly man with a headache who was seen at our
University-affiliated clinic across town from SFGH and underwent BOTH a
negative head CT and a brain MRI and didn’t pay a dime – the outpatient MRI was
“charged” on his bill at $3,644, of which Medicare paid the incredibly reduced
“price” of $275 and Medi-cal picked up the $178 that the patient would have
been responsible for. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<div class="MsoNormal" style="text-indent: .5in;">
The man’s headache, by the way,
resolved with “meditation.” That’s probably a good prescription for all of us
right now. </div>
<div class="MsoNormal" style="text-indent: .5in;">
<br /></div>
<!--EndFragment--></div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com3tag:blogger.com,1999:blog-3537910058667804944.post-13329566747931414612012-05-01T08:00:00.000-04:002012-05-01T08:00:16.354-04:00The case of the $517 chest x-ray<br />
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<i>The following anecdote is from Dr. Paul Abramson, a physician based in San Francisco, and originally appeared on his blog <a href="http://mydoctorsf.com/">http://mydoctorsf.com</a>, and is part of a series of posts on this topic</i></div>
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So the story goes like this. A patient of mine needed a chest x-ray. He doesn’t have health insurance, so rather than just give him a requisition and send him to the local hospital, I decided to do a little calling around on his behalf to find out what the damage would be… <strong><br /></strong></div>
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<strong>Vendor #1: A well-known local hospital</strong></div>
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I called up the radiology department and asked them how much a PA and Lateral Chest X-ray would cost. “I don’t know – we don’t have that information” I was told by the clerk. The radiologist gave me the same answer. They both said I should just send the patient over and he would find out the cost when he received the bill.<a href="http://mydoctorsf.com/wp/wp-content/uploads/2010/08/nl_cxr.jpg" style="color: #163e60; font-family: Verdana, Geneva, Arial, Helvetica, sans-serif; letter-spacing: 1px; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: underline;"><img alt="" class="alignright size-full wp-image-153" height="281" src="http://mydoctorsf.com/wp/wp-content/uploads/2010/08/nl_cxr.jpg" style="border-bottom-color: rgb(26, 76, 116); border-bottom-style: solid; border-bottom-width: 1px; border-color: initial; border-left-color: rgb(26, 76, 116); border-left-style: solid; border-left-width: 1px; border-right-color: rgb(26, 76, 116); border-right-style: solid; border-right-width: 1px; border-style: initial; border-top-color: rgb(26, 76, 116); border-top-style: solid; border-top-width: 1px; float: right; margin-bottom: 10px; margin-left: 10px; margin-right: 10px; margin-top: 10px;" title="nl_cxr" width="300" /></a></div>
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That seemed a little dumb. Since when do we go into stores and buy things without knowing the price?</div>
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So after 4 additional phone calls and about 2 hours, my assistant and I finally reached Bob who is in charge of uninsured patient billing. He was able to tell me the price: <strong>$517</strong>.</div>
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For a PA and Lateral Chest x-ray.</div>
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For cash paying patients who pay at the time of service and <em>know to ask for the<br />“20-20″ discount</em> by name, the price ends up being reduced to<strong>$310.20.</strong> But you have to know the secret code word.</div>
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Time to receive report in my office: 2-3 days.</div>
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Quality: Good</div>
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<strong>Vendor #2: Free-Standing Private Radiology Office (call us if you wish to know which one)</strong></div>
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I called up and the receiptionist answered on the first ring. I asked how much for a PA and Lateral Chest x-ray.</div>
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An immediate answer: <strong>$73</strong>.</div>
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Time to receive report in my office: 1 hour.</div>
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Quality: Just as Good</div>
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So my quesiton is this. How can the hospital be charging 4.25 times as much as the place down the street to cash-paying patients, for the same product and actually inferior response time? (or 7 times as much without the secret code word). I know, “cost shifting” is a common refrain. But that just doesn’t fly any more.</div>
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And what’s more disturbing, how can it be so difficult to find out the price when you call up and ask?</div>
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So many doctors just send their patients to the hospital x-ray department or lab without thinking that it may bankrupt them. And many doctors have no idea that the price spread can be so great.</div>
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It’s time we developed some more price transparency in health care. I know there are companies trying to create online price comparison databases. That is good, but really every entity should be required to have front-line staff know the prices<br />for every service they offer. That way patients and doctors can make rational decisions about how to get each patient what they need.</div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com21tag:blogger.com,1999:blog-3537910058667804944.post-7084813466694886652012-04-23T08:00:00.000-04:002012-04-23T08:00:43.772-04:00Talking to Your Doctor About Health CostsIn a <a href="http://www.costsofcare.org/images/stories/pdf/patient_brochure_jou.pdf">new brochure developed for patients</a>, medical student Jessica Jou writes, "Most people can find an estimate to hire a babysitter or fix a car. But what about a chest x-ray? Even in the age of Google, you may be surprised by how difficult it is to learn the cost of your health care."<br />
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This has become increasingly important as more patients find themselves with health plans that require the first several thousand dollars of expenses to be paid out of pocket. It doesn't help that talking to your doctor about health costs can be uncomfortable.<br />
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Using insights from hundreds of patient anecdotes that Costs of Care received during our last two essay contests, Jessica lists lessons learned and helpful tips, including answers to questions such as "What if my physician refers me to the billing department?" and "What kinds of cost-aware decisions can my physician make for me?<br />
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<a href="http://www.costsofcare.org/images/stories/pdf/patient_brochure_jou.pdf">Download Jessica's brochure</a> directly from the Costs of Care website.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC6ijEYnZqpgOOam6XBhOabZ10ImituAh-HNDgPoZ3r0U27nu4YZRfoaeCWOln737VJtFL4CWKV2ePmQvwhch4WFvSd2tu1BBqDhC2xiVaNNAH1Hw9Ep8Nd1F-D54N6RJX_n1GZfVibdw/s1600/Jou.tiff" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC6ijEYnZqpgOOam6XBhOabZ10ImituAh-HNDgPoZ3r0U27nu4YZRfoaeCWOln737VJtFL4CWKV2ePmQvwhch4WFvSd2tu1BBqDhC2xiVaNNAH1Hw9Ep8Nd1F-D54N6RJX_n1GZfVibdw/s200/Jou.tiff" width="132" /></a></div>
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><span class="Apple-style-span" style="color: #222222;"><span class="Apple-style-span" style="border-collapse: collapse;">Jessica Jou </span></span><span class="Apple-style-span" style="border-collapse: collapse; color: #222222;">is currently a second year medical student at the Tufts University School of Medicine. She grew up in Taiwan where medical insurance is universally provided by the government. While in college, she lead a team of physicians and students to provide healthcare to rural villages in Nepal. They are now in their fifth year of service. And after working with the uninsured population in Boston at the Sharewood Project, she is inspired to empower patients and physicians alike to start the conversation about healthcare costs</span></span>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com3tag:blogger.com,1999:blog-3537910058667804944.post-25308813596102080022012-04-22T08:00:00.000-04:002012-04-22T08:00:05.451-04:00Savvy patient finds hidden discounts just by asking<br />
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<span style="font-family: Arial; font-size: 10pt;"><i>The following anecdote was written by Suzanne Nesmith, a patient from Arkansas who was a finalist in the <a href="http://www.prweb.com/releases/2011/12/prweb9050881.htm">2011 Costs of Care Essay Contest</a>.</i></span></div>
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<span style="font-family: Arial; font-size: 10pt;"><i><br /></i></span></div>
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<span style="font-family: Arial; font-size: 10pt;">My husband and I have
been self-employed for many years, and though our income is quite limited, we</span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;"> </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">have always been careful with our finances, have always managed to live within our
means, and have always </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">paid our bills without assistance. We had private
health insurance coverage and saw premium increases each </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">year. Then to
avoid further increases, coverage of office visits outside of deductible was
dropped, and our </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">deductible was raised to $4500. Finally, about seven years ago, the cost became prohibitive
for us; when yet </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">one more increase was announced, our monthly premium payment
would amount to approximately 30% of </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">our monthly income. We were in relatively good health
and, in fact, in 10 years we had only one health </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">insurance claim-- an emergency room visit when our daughter fractured her arm in a roller
skating accident. </span></div>
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<span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">We did not do it lightly, but we made the decision to drop
the health insurance coverage we could no longer </span><span style="font-family: Arial; font-size: 10pt;">afford. </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">We started to research
alternatives and found Samaritan Ministries International, a Christian need
sharing </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">group. It was through SMI we were first made aware of how
prices for medical charges could vary, that </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">discounts were often made to self-pay patients, and what a
difference simply asking about prices could make. </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">What valuable information—for anyone, but especially for the
self-paying!</span></div>
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<span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">Recently, I required more than
routine health care and my doctor ordered a CT scan. I called three </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">facilities to ask what the cost of the ordered CT scan would
be, understanding that it would not include the </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">physician’s reading fee only and that it would be only an
estimate. The first things that
was obvious was that </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">hospitals are unfamiliar (and it appears to me
uncomfortable) with being asked this question. I was often </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">transferred from one department to another, usually ending
up in billing or finance, and more than once, was </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">told, “I’ve
never been asked that before.” When finally connected with the
person who could give me that </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">information, I also asked if any discount was available for
self-pay patients, and for cash payment.
The results </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">were so interesting that I put them in the form of a chart to show to my
doctor. </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;"> </span></div>
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<span style="font-family: Arial; font-size: 10pt;">estimate <o:p></o:p></span></div>
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<span style="font-family: Arial; font-size: 10pt;">discounts<o:p></o:p></span></div>
</td>
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<span style="font-family: Arial; font-size: 10pt;">estimated result<o:p></o:p></span></div>
</td>
</tr>
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<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 77.55pt;" valign="top" width="78"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">XXX<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 51.1pt;" valign="top" width="51"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">$2921<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 221.3pt;" valign="top" width="221"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">20% discount if contacted within 10 days of billing, and
paid with first billing<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 55.05pt;" valign="top" width="55"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">$2441<o:p></o:p></span></div>
</td>
</tr>
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<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 77.55pt;" valign="top" width="78"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">XXX<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 51.1pt;" valign="top" width="51"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">$5459<o:p></o:p></span></div>
</td>
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<span style="font-family: Arial; font-size: 10pt;">20% discount for self-pay<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">20% discount if balance paid within 1 month<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 55.05pt;" valign="top" width="55"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">$3276<o:p></o:p></span></div>
</td>
</tr>
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<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 77.55pt;" valign="top" width="78"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">XXX<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 51.1pt;" valign="top" width="51"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">$3849<o:p></o:p></span></div>
</td>
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<span style="font-family: Arial; font-size: 10pt;">58% discount if ½ paid in advance and balance paid in next billing cycle.<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 55.05pt;" valign="top" width="55"><div class="MsoNormal">
<span style="font-family: Arial; font-size: 10pt;">$1616<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
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<span class="Apple-style-span" style="font-family: Arial; font-size: 13px;"><br /></span></div>
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<span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">Not only did we have the benefit of cost savings by comparing prices, we
had additional cost </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">savings through discounts by simply asking—these might have
otherwise been missed. My doctor
has since </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">ordered a colonoscopy. So, I called different facilities and
was quoted prices of anywhere from $1288 to </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">$1500; and in each instance it was
not until I simply asked about any discounts was I told that I could arrange </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">for a 50% discount if I would simply
ask to pay (even as little as 1/4<sup>th</sup> payment) at the time of
service. Simply </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">asking about price and discounts
will now be an essential part of my personal responsibility and proactive </span><span class="Apple-style-span" style="font-family: Arial; font-size: 13px;">attitude concerning my own health care.</span></div>
<span style="font-family: Arial; font-size: 10pt;"> </span>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com12tag:blogger.com,1999:blog-3537910058667804944.post-60065282451101224642012-03-26T09:00:00.000-04:002012-03-26T09:00:01.976-04:00The Letterman Approach to Cost Awareness<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiI6FDCVaInE5YABUSLyPTvShLj6dBayUCNtvEEqajEjNQzF8bdLa8n5_Ni4-hxa4lllLC8qeL_5LwDuCMYnurSeFTv5JWUg18OtzPoJH5a_s1vBLrijes8aBX5tgbkG_Cl7MZtJC-gvI4/s1600/ChrisMoriartes.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiI6FDCVaInE5YABUSLyPTvShLj6dBayUCNtvEEqajEjNQzF8bdLa8n5_Ni4-hxa4lllLC8qeL_5LwDuCMYnurSeFTv5JWUg18OtzPoJH5a_s1vBLrijes8aBX5tgbkG_Cl7MZtJC-gvI4/s1600/ChrisMoriartes.jpg" /></a><i><span style="color: #333333; font-family: Arial; font-size: 10.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt;">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. </span></i></div>
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Who <a href="http://www.newyorker.com/online/blogs/culture/2011/12/i-hate-top-ten-lists.html">doesn’t love</a> a Top 10 list? Creating them is an <a href="http://blogs.phoenixnewtimes.com/uponsun/2010/12/the_year-end_top_10_albums_li.php">art form</a>.<span> </span>So when it was formally proposed by <a href="http://www.nejm.org/doi/full/10.1056/NEJMp0911423">Dr. Brody in 2010 in the NEJM</a> that each specialty create their own “Top 5 list” of unnecessary care, it seemed like a straightforward – if not downright provocative – suggestion.</div>
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“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.</div>
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And yet, thus far the only groups that have seemed to have <a href="http://archinte.ama-assn.org/cgi/content/short/171/15/1385">taken him up on the suggestion</a> have been the primary care specialties of Internal Medicine, Family Medicine and Pediatrics - notably amongst the least compensated fields in health care.</div>
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<o:p> </o:p>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.”</div>
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Not to say that there hasn’t been some progress. The ABIM Foundation has indeed put together an <a href="http://www.abimfoundation.org/News/ABIM-Foundation-News/2011/ABIM-Foundation-Announces-the-Choosing-Wisely-Campaign.aspx">impressive list of organizations</a> participating in their “Choosing Wisely” campaign. They also have begun to be <a href="http://www.abimfoundation.org/News/ABIM-Foundation-News/2012/Costs-of-Care.aspx">instrumental in funding projects</a> towards this goal. <a href="http://www.costsofcare.org/">Costs of Care</a>has highlighted far-reaching areas of non-value-based care, including a <a href="http://www.costsofcare.blogspot.com/2012/03/bottom-line-what-is-good-for.html">recent thoughtful essay about robotic surgery</a>. We must now consolidate on these small gains and move this forward across all specialties in medicine.</div>
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It is worth noting that one of our first steps in <a href="http://costsofcare.blogspot.com/2012/02/cost-awareness-in-health-care-idea.html">creating our curriculum at UCSF</a> 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).<span> </span></div>
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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.<span> </span>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.</div>
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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.</div>
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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.</div>
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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.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2w-YNdP7dpE9GSpFPBMeCxK6XdXPWnjcenFqxRDI3wpdlxjo2vFYfb13ikq1MUqdVtLyj0jTcfFhPbbk4HO31dAwNEJl4AQDk4hRsB2EupsY83UYCLJX5gzXG4a0WR0aglpP_7w43cB4/s1600/UCSF+Cost+Awareness.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2w-YNdP7dpE9GSpFPBMeCxK6XdXPWnjcenFqxRDI3wpdlxjo2vFYfb13ikq1MUqdVtLyj0jTcfFhPbbk4HO31dAwNEJl4AQDk4hRsB2EupsY83UYCLJX5gzXG4a0WR0aglpP_7w43cB4/s1600/UCSF+Cost+Awareness.jpg" /></a></div>
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<br /></div>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com2tag:blogger.com,1999:blog-3537910058667804944.post-57407572771311568312012-03-12T08:30:00.000-04:002012-03-12T08:30:01.839-04:00A Question of Worth<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7b4Nu3vI4nxsNtj8S49PvpsTX55ZsawHfgREDTWhG87XpopNZSJHZUDJ-R3ePFhmBkVv41PaxmM_tWgJFszfYpiND9e-X9yVLFzqGRLl2SLUySoDISPAoWazmSzOCZVgCW4iT5or5yeI/s1600/eijean-wu.jpg" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 150px; height: 200px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7b4Nu3vI4nxsNtj8S49PvpsTX55ZsawHfgREDTWhG87XpopNZSJHZUDJ-R3ePFhmBkVv41PaxmM_tWgJFszfYpiND9e-X9yVLFzqGRLl2SLUySoDISPAoWazmSzOCZVgCW4iT5or5yeI/s200/eijean-wu.jpg" border="0" alt="" id="BLOGGER_PHOTO_ID_5718799677375087138" /></a><p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;"><i>Dr. Eijean Wu is a gynecologic oncology fellow at the University of Southern California Medical Center, and was a finalist in the <a href="http://www.prweb.com/releases/2011/12/prweb9050881.htm">2011 Costs of Care Essay Contest</a>.</i></span></p><p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">As an OB/GYN resident, I tried to reconcile quality and cost of care every day. This is the story of one patient who cost the system a lot of money, but I don’t know to this day if it was too much.</span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">Cheryl (name changed) had HIV, a history of cervical cancer, and 3 kids. At age 35, she had been cured from cervical cancer after surgery and radiation therapy. However, due to treatment-related fistulas, she had been in and out of the hospital for most of the year. I was taking call for the gynecology service the last time her family brought her in, delirious and with black, sticky stool oozing from an opening in her unhealed abdominal incision. She needed wound care and close monitoring in the intensive care unit (ICU). I paged the ICU team.</span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">The ICU fellow came promptly, and briskly refused to accept her to his unit. “She is a poor use of scarce resources,” he stated matter-of-factly. “Further treatment is <i style="mso-bidi-font-style:normal">futile</i>.” Without missing a beat, I looked him in the eye and countered, “What if this was your sister? Your mom?” He relented begrudgingly, but added, “This is why health care is so expensive in this country. You surgeons don’t know when to let go.”</span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">Thanking him for accepting my patient, I went back to Cheryl to clean up her wound. She grabbed my arm and whispered, "Dr. Wu, I'm scared. Don't leave." I assured her that we would do everything we could to get her back to her kids. Afterall, her cancer was gone and her HIV viral load was undetectable. We couldn’t quit now. Two days later, Cheryl was leaving her room to sneak a cigarette. One day after that, she was found dead in her hospital bed by a nurse checking vital signs. Cheryl had quietly passed away in her sleep from a massive gastrointestinal bleed.<o:p></o:p></span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">Had I gotten too attached and lost sight of the big picture, as the ICU fellow purported? Who deserved that last ICU bed that night? Someone who would have only cost taxpayers $10,000, $100,000, or $1,000,000 during her stay? Would it have mattered to the hypothetical taxpayer that Cheryl had lost her professional job and employer-based insurance due to her long treatment, then lost her home, then spent down her income and thus qualified for Medicaid? Was it my responsibility to be considering resource allocation while my patient was critically ill? Besides, the ICU fellow abandoned his cost-conscious argument quite quickly at the mere suggestion that he would do otherwise for his family member.</span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">I had worked in the private, public, and not-for-profit sectors prior to going to medical school. I had pondered the roles of corporations, governments, and single-issue foundations in shaping our health care system. I knew about the slippery politics, limited data, legal pressures, and economic realities. Yet, time and time again when my patients come into the emergency room or are lying on the operating table or get better or worse after some intervention, I struggle to see the forest for the trees.</span><span class="Apple-style-span" style=" ;font-family:Arial;font-size:15px;"> </span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">On some level, I don’t think my patients want me to be thinking about the sustainability of the health care system when I’m counseling them about their options. They want to know that I am their unwavering advocate. Their interests are my top priority in that fiduciary relationship. If I suggested more or less, it would only be watching out for them, not for the general public.</span><span class="Apple-style-span" style=" ;font-family:Arial;font-size:15px;"> </span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">Yet, my experience tells me that providers, the people who oversee these cherished doctor-patient interactions, must play a principal role in revamping this overwrought and overpriced health care structure that does not produce the quality and safety outcomes any moral society would demand. Doctors wrestle with the nuances and inefficiencies of the institution every day. Medicine is not mathematics, but it is prudent to inject a measure of cost-awareness into our diagnostic work-ups, treatment algorithms and clinical trials. It may seem distasteful to knowingly put a monetary value on life, but we already do that calculation with each clinical decision we make. Higher quality can be affordable and accessible.</span></p> <p class="MsoNormal"><span style="font-size:11.0pt;mso-bidi- font-family:Arial;font-size:12.0pt;">So for now, I continue to navigate that difficult space between being a good doctor and a conscientious citizen. I will see many more patients like Cheryl in my career. They will always be pushing me to do better. <o:p></o:p></span></p> <!--EndFragment-->Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com6tag:blogger.com,1999:blog-3537910058667804944.post-5106346982984753682012-03-05T08:00:00.004-05:002012-03-06T12:36:19.599-05:00The Bottom Line: What is good for shareholders may not be good for patients<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeABWu3GQ5aszAWbx11k1gg0kGm_OKzJ5rzvpYkPLeevz4BP60k0e4hDO2ak3tVXqrL_awf7CJH-d3be4Xy9bXRfxbtAGMPtQqDs_Dy9mEX62htDBrR8J0EM1HRwre5VFMGi04yvGcU3U/s1600/kelly+wright.JPG"><img id="BLOGGER_PHOTO_ID_5715869194309676786" style="FLOAT: left; MARGIN: 0px 10px 10px 0px; WIDTH: 150px; CURSOR: hand; HEIGHT: 200px" alt="" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeABWu3GQ5aszAWbx11k1gg0kGm_OKzJ5rzvpYkPLeevz4BP60k0e4hDO2ak3tVXqrL_awf7CJH-d3be4Xy9bXRfxbtAGMPtQqDs_Dy9mEX62htDBrR8J0EM1HRwre5VFMGi04yvGcU3U/s200/kelly+wright.JPG" border="0" /></a> <em>This post was written by <a href="http://rightonhereford.wordpress.com/">Dr. Kelly Wright</a>, a minimally invasive gynecologic surgery fellow in the Boston area.</em><br /><br /><br /><p>It’s cool. So cool, that President Obama used one. So cool, it’s been on the cover of Newsweek. It’s been in multiple television commercials, radio advertisements, highway billboards, and was even coined one of the top 14 medical breakthroughs of 2011 by Boston Magazine, a city teeming with medical innovation. Yet surgeons and health economists are unable to explain the fascinating rise of robotic-assisted surgery.<br /><br /><br /><p>Currently, a single company manufactures and distributes the robot, a line of surgical equipment used to conduct robotic-assisted surgery. The robotic system consists of a surgeon’s console with 3-dimensional high definition vision and a patient-side cart featuring robotic arms with proprietary wristed instruments. The system translates the surgeon’s natural hand movements on instrument controls into corresponding movements of instruments inside the patient, giving the surgeon control, range of motion, and depth of vision similar to open surgery.<br /><br /><br /><p>The sole manufacturer hopes to establish the robot as the standard for surgical procedures by encouraging surgeons and hospitals to adapt the technique while marketing aggressively to patients about the benefits of robotic surgery. As of June 2011, the manufacturer had installed 1,933 robotic systems. They estimate that 278,000 robotic-assisted surgical procedures were performed in 2010, up 35% from 2009, and aim to achieve one million annual procedures in the United States over the next few years (Investor Report 2011). To achieve this goal, the manufacturer strategically markets to smaller hospitals and surgeons who may not be skilled at conventional laparoscopy to give them an edge for attracting patients.<br /><br /><br /><p>The robotic systems are sold to hospitals for a cost of $1.0 - $2.3 million, depending on the version. Mandatory annual service agreements range from $100,000 to $170,000 per year. These prices are paying off for the manufacturer. In 2010, the company reported revenues of over $1.4 billion from the sale of systems, and most recently, a 38% increase in instrument sales and 25% growth on systems revenues for the third quarter of 2011 (S&P stock report 2011). Since 2006, the company reports gross profits at 66%-73% of revenue.<br /><br /><br /><p>Who regulates these costs? Only the sole manufacturer does. The robotic surgical system is the only FDA-approved robotic system on the market. In addition, the manufacturer owns or has exclusive rights to over 2000 patents and patent applications, derived from the acquisition of other robotic devices and companies. Extensive regulations administered by the FDA act as a barrier to entry by other competitors, and since the manufacturer’s acquisition of its major competitor in 2003, there are no direct commercial competitors in the robotic-assisted surgery market. Without competition, a single company runs the robotic market without any regulation.<br /><br /><br /><p>Shareholders are thrilled. The stock value continues to rise in a recession and has just passed the $500 per share mark. Patients want it. Hospitals are buying it. So why isn’t everyone excited about robotic-assisted surgery? </p><br /><p>Unfortunately, the exuberant and rapid adoption of robotic-assisted surgery has occurred in the absence of randomized trial evidence validating its use. Instead, marketing by the manufacturer accounts for the exponential use of robotic surgery over the past five years rather than clinical evidence.<br /><br /></p><br /><p>In fact, researchers from Johns Hopkins found that hospital websites, using manufacturer-provided content, misled patients with clinical claims that have not been substantiated (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Robotic%20surgery%20claims%20on%20United%20States%20hospital%20websites">1</a>). The researchers found approximately 4 in 10 hospital websites in the United States publicize the use of robotic surgery. What was most concerning was that 89% of these hospital websites made a statement of clinical superiority over conventional surgeries, the most common being less pain, shorter recovery, less scaring, and less blood loss. 32% made a statement of improved cancer outcome, and none mentioned any risks or costs.<br /><br /><br /><p>The evidence is just beginning to emerge to the contrary. Literature has shown that while clinical outcomes are similar to or no better than conventional surgery, the robotic technique is more expensive than conventional laparoscopy for a number of surgeries including cholecystectomy (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Robotic-assisted%20versus%20laparoscopic%20cholecystectomy%253A%20outcome%20and%20cost%20analyses%20of%20a%20case-matched%20control%20study">2</a>) and hysterectomy for endometrial cancer (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Cost%20comparison%20among%20robotic%252C%20laparoscopic%252C%20and%20open%20hysterectomy%20for%20endometrial%20cancer">3</a>). For some procedures, including benign hysterectomy, sacrocolpopexy (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Cost-Minimization%20Analysis%20of%20Robotic-Assisted%252C%20Laparoscopic%252C%20and%20Abdominal%20Sacrocolpopexy">4</a>), and myomectomy (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Cost%20Analysis%20of%20Abdominal%252C%20Laparoscopic%252C%20and%20Robotic-Assisted%20Myomectomies">5</a>), the robotic technique is even more expensive than conventional laparoscopy and laparotomy. Despite the large number of robotic prostatectomies performed to date, evidence has yet to show improved clinical, cancer, or cost outcomes for robotic prostatectomy (<a href="http://www.ncbi.nlm.nih.gov/pubmed/22025192">6</a>). In addition, studies show that robotic-assisted surgery is consistently $1600-$3000 more than conventional laparoscopy or open surgery (<a href="http://www.nejm.org/doi/full/10.1056/NEJMp1006602">7</a>,<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=Are%20costs%20of%20robot-assisted%20surgery%20warranted%20for%20gynecological%20procedures">8</a>). Our institutional data for hysterectomy showed that robotic-assisted surgery translated into a $6000-$10,000 increase in expenses to the patient over all other methods of hysterectomy. If the 600,000 hysterectomies performed in the United States each year were all converted to robotic-assisted hysterectomies, this would represent a $3.6 billion to $6 billion increase in patient costs. An increase in patient costs for no clinical benefit.<br /><br /><br /><p>What does the literature show? High-volume subspecialty surgeons have better patient outcomes and use less hospital resources and health-care dollars than low-volume, less-skilled surgeons (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=the%20effects%20of%20surgeon%20volume%20on%20outcomes%20and%20resource%20use%20for%20vaginal%20hysterectomy&cmd=correctspelling">9</a>). In fact, a hospital’s investment into a moderately priced robotic system over 5 years would provide an average salary for a fellowship-trained minimally invasive surgical subspecialist (conventional laparoscopist) for 10 years. Instead of investing in a marketing technique, hospitals should invest in and develop talented high-volume surgeons because the clinical benefit is proven.<br /><br /><br /><p>In a time where medical bills are the leading cause of personal bankruptcy in the United States and health care spending is nearly 18% of the GDP, why are patients paying more for a technique without any proven benefits over conventional therapies? Why are hospitals marketing robotic-assisted surgery to patients without reviewing the manufacturer’s claims? Why are we allowing a single company’s bottom line to increase while insurance premiums and out-of-pocket spending for patients increase every year? We have to stop pursuing things because they are marketed to us. In medicine, there are always procedures that are feasible, but they are not always the right clinical choice; similarly, they are not always the cost-effective choice. In the case of robotic-assisted surgery, it shows neither improved clinical outcomes nor lowered costs.</p>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com1tag:blogger.com,1999:blog-3537910058667804944.post-37653448032364390432012-02-27T08:30:00.002-05:002012-02-27T08:30:05.102-05:00Costs of Care...and Coercion?<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdQRcCg3OW61Y5B15X41nHq0Xy20h0S4JdLLqx1dGakKsVijvAHkm_i2AHWCKp9cHTFsAkUou2ByYrDjoXhwtuSshCSQhrOE5OvDVO-HY1tmvrllzmF1ZznKYw2U0oB6GubU9yqguxjbY/s1600/jschumann-AAAS-photo1.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 180px; height: 180px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgdQRcCg3OW61Y5B15X41nHq0Xy20h0S4JdLLqx1dGakKsVijvAHkm_i2AHWCKp9cHTFsAkUou2ByYrDjoXhwtuSshCSQhrOE5OvDVO-HY1tmvrllzmF1ZznKYw2U0oB6GubU9yqguxjbY/s200/jschumann-AAAS-photo1.jpg" alt="" id="BLOGGER_PHOTO_ID_5713470328090794322" border="0" /></a><br /> <style> <!-- /* Font Definitions */ @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} @font-face {font-family:"MS Mincho"; mso-font-alt:"MS 明朝"; mso-font-charset:128; mso-generic-font-family:modern; mso-font-pitch:fixed; mso-font-signature:-536870145 1791491579 18 0 131231 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:"Times New Roman"; mso-ascii-font-family:Cambria; mso-fareast-font-family:"MS Mincho"; mso-hansi-font-family:Cambria; mso-bidi-font-family:"Times New Roman";} @page Section1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.Section1 {page:Section1;} --> </style> <p class="MsoNormal"><i style="">The following anecdote is written by Dr. John Schumann, Associate Professor of Medicine at the University of Oklahoma. His story was a finalist in the <a href="http://www.prweb.com/releases/2011/12/prweb9050881.htm">2011 Costs of Care Contest</a>, and will be featured on American Public Media's <a href="http://www.marketplace.org/">Marketplace</a>.</i></p><p class="MsoNormal"><i style=""><br /></i></p><p class="MsoNormal"><i style="">[All names and identifying features of characters in this story have been changed.]</i></p><p class="MsoNormal"><i style="mso-bidi-font-style:normal"><br /></i></p> <p class="MsoNormal"> </p> <p class="MsoNormal">Nora, a third year medical student, came to me in moral distress.</p> <p class="MsoNormal"> </p> <p class="MsoNormal">Ms. DiFazio, one of the hospitalized patients on her Internal Medicine rotation, was frightened to undergo an invasive (and expensive) medical procedure: cardiac catheterization.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">The first year doctor [‘intern’] with whom Nora was paired, Dr. White, vented to her:</p> <p class="MsoNormal"> </p> <p class="MsoNormal">“These patients come to us seeking our help and then refuse what we have to offer them,” Dr. White steamed.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">At the bedside, the intern demanded to know why Ms. DiFazio refused the procedure. When no reason beyond “I don’t want to” was offered, Dr. White told Ms. DiFazio that there was no longer cause for her to stay in the hospital.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">By declining the procedure, Dr. White informed Ms. DiFazio that she would have to sign out ‘against medical advice’ (AMA). To signify this she would have to acknowledge that leaving AMA could result in serious harm or death. In addition, Ms. DiFazio would bear responsibility for any and all hospital charges incurred and not reimbursed by her insurance due to such a decision.<br /></p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">“The threat of a huge hospital bill got Ms. DiFazio to stay and take the test,” Nora related.<span style="mso-spacerun: yes"> </span>“It just seems so wrong to bludgeon a patient this way. Can it possibly be true?”</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">I’d been out of medical school myself for eight years at that point; until then I’d never heard that patients who sign out against medical advice risk bearing the costs of their hospitalization. What about a patient’s freedom of choice, or as we like to call it in medicine, their <i style="mso-bidi-font-style:normal">autonomy</i>?</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">I told Nora I didn’t know, but was determined to find out. Ethically, the notion that patients in the hospital must do our bidding or pay the price seemed dubious. Yet in a world of co-pays, deductibles, and ‘preexisting conditions,’ a mere grain of plausibility made this idea seem vaguely credible.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">I asked around. To my surprise, many fellow attending physicians told me they had been taught the very same thing<a name="_GoBack"></a>. My colleagues had trained at teaching institutions around the country, so I began to see this as a pervasive and widely-held belief.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">I straw polled some of our residents, and like Dr. White, found that they almost unanimously believed that AMA discharges incurred financial penalties. Where did they learn this?</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal"><i style="mso-bidi-font-style:normal">From their attendings. </i></p> <p class="MsoNormal"><i style="mso-bidi-font-style:normal"> </i></p> <p class="MsoNormal"><i style="mso-bidi-font-style:normal">From the nurses. </i></p> <p class="MsoNormal"><i style="mso-bidi-font-style:normal"> </i></p> <p class="MsoNormal"><i style="">From the AMA form itself, with language stating that the patient, by signing, acknowledges financial risk.</i></p><p class="MsoNormal"><i style="mso-bidi-font-style:normal"><br /></i></p> <p class="MsoNormal"> </p> <p class="MsoNormal">We needed to find the truth.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">Colleagues helped us sift through nearly ten years of AMA discharges from our teaching hospital. And though the results are in press at a medical journal, I can say that out of hundreds of cases of AMA discharges over a decade, in only a handful was the bill was not paid—and that was invariably due to ‘administrative issues,’ not because of the AMA discharge.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">I also thought it important to go to the source: I called the insurance companies themselves. I talked with VPs and media relations people from several of the nation’s largest private insurance carriers. </p> <p class="MsoNormal"> </p> <p class="MsoNormal">Each of them told me that the idea of a patient leaving AMA and having to foot their bill is bunk: nothing more than a medical urban legend.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">They were glad to tell me so, as this was a rare occasion of insurance companies looking magnanimous. One director went so far as to poll his company’s own medical directors—a half dozen of them--and found that several of them had been taught and believed the canard about AMA discharge and financial responsibility. He was happy to set the record straight.</p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">So patients and doctors beware: The next time you or your loved one has decided that it’s time to leave the hospital, don’t let us doctors coerce you into staying by threatening you with the bill.<br /></p><p class="MsoNormal"><br /></p> <p class="MsoNormal"> </p> <p class="MsoNormal">It simply isn’t true that leaving against medical advice makes it fall entirely upon your pocketbook.</p> <p class="MsoNormal"> </p> <p class="MsoNormal">Future Noras should feel empowered to set the record straight with their interns and residents. Most of all, the Ms. DiFazios of the world won’t have to submit to procedures that they don’t wish to undergo.</p>Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com10tag:blogger.com,1999:blog-3537910058667804944.post-10044609509384946712012-02-20T00:42:00.006-05:002012-02-20T08:16:46.312-05:00Cost Awareness in Health Care: An Idea Whose Time Has Come<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrboi87mq9sarRahzWyenZoiCU__0rPv_aWJEIH9mCBAehDMNuYwR9pYmhTqKp0hqZ7Vy4pFxD_cKCb8oil_vMe7rab5eZARL9SKFMVfIab3NEQiXvs581u8VQa47P2qypBu2QYHpd1dY/s1600/ChrisMoriartes.jpg"><img style="float:left; margin:0 10px 10px 0;cursor:pointer; cursor:hand;width: 165px; height: 165px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrboi87mq9sarRahzWyenZoiCU__0rPv_aWJEIH9mCBAehDMNuYwR9pYmhTqKp0hqZ7Vy4pFxD_cKCb8oil_vMe7rab5eZARL9SKFMVfIab3NEQiXvs581u8VQa47P2qypBu2QYHpd1dY/s200/ChrisMoriartes.jpg" alt="" id="BLOGGER_PHOTO_ID_5711205874364211522" border="0" /></a><em>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. </em><br /><br /><em><strong>“Nothing is as powerful as an idea whose time has come.” – Victor Hugo<br /></strong></em><br />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.<br /><br />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 <a href="http://jama.ama-assn.org/content/289/11/1430.full">fair bar to hop</a>, 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 <a href="http://www.nejm.org/doi/full/10.1056/NEJMra072149">significant amount of radiation</a> and a hospital bill that now included an approximately $2,500 imaging charge. Nobody seemed to flinch, but it got me thinking.<br /><br />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 <a href="http://www.nejm.org/doi/full/10.1056/NEJMp0911502">Dr. Molly Cooke in the New England Journal of Medicine in 2010</a>. And yet, it turns out that the <a href="http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf">ACGME officially states (under their Systems-Based Practice core competency)</a> 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.<br /><br />But this has all started to change.<br /><br />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 (<a href="http://www.nejm.org/doi/full/10.1056/NEJMp1111087">The New England Journal of Medicine</a>, <a href="http://jama.ama-assn.org/content/306/6/650">JAMA</a>, <a href="http://www.annals.org/content/155/6/386.abstract">The Annals of Internal Medicine</a>, <a href="http://archinte.ama-assn.org/cgi/content/full/170/7/584">The Archives of Internal Medicine</a>) and the popular press (<a href="http://www.nytimes.com/2009/06/14/opinion/14sun1.html">The New York Times</a>, <a href="http://articles.latimes.com/2011/sep/19/news/la-heb-health-care-costs-residents-20110919">The LA Times</a>, <a href="http://www.bloomberg.com/news/2011-07-12/medicine-s-big-mystery-what-does-treatment-cost-mimi-ferraro.html">Bloomberg</a>), that the movement is starting to reach a critical mass. To see a <a href="http://www.mercurynews.com/mediacenterrefer/ci_19898736">patients’ hospital bill broken down and printed with a heart felt commentary by their daughter in a newspaper</a> would have likely been unimaginable a short time ago. The call-to-arms seemed crystal clear during a <a href="http://capsules.kaiserhealthnews.org/wp-content/uploads/2011/12/IHI-FINAL-Forum-2011-Berwick-Plenary.pdf">recent speech by Don Berwick</a>.<br /><br />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.<br /><br />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.Neel T. Shahhttp://www.blogger.com/profile/17037130471163838831noreply@blogger.com6