Teaching Costs of Care: Opening Pandora's Box

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

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


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


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


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


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


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


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


--Vineet Arora MD MAPP

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

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

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

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

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

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

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

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

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

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

I encourage you to go check it out.

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

Surgery at $147 per minute

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

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

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

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

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

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

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

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

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

Medical Students Write Handbook for their Peers

Elisabeth Askin is a third year medical student at Washington University in St Louis and co-author of The Health Care Handbook for medical students.

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.

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.

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.

Thus, the question is: how do we combine doing what is best for each patient with understanding our role in the larger picture?

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.

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.

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.

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.

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.

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.

The New Generation of Medical Students

The following post  is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard

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.

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.

The definition of a “good physician” has changed in the last few years.  It is no longer sufficient to limit ourselves to medicine; we must 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^th 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. 

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^st century.

A recommendation to minimize costs backfires

The following anecdote is by Alexis Ball, the daughter of a patient from New Mexico. Her story was originally submitted to the 2011 Costs of Care Essay Contest.

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.

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.

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,

“Hello Ms. Ball! I understand that you are reordering the drainage and dressing kits , unfortunately they are out of plan for your insurance”

We were dumbfounded. How could the insurance cover a system in which they did not support the supplies?

“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”

Our jaws dropped.

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.

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.

Skipping the Daily Blood Draw

The following anecdote is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard University





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.

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.

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.”

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.

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.