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2012 Essay Contest Finalists Announced!

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.

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.

Congratulations to our finalists! All of their essays will be published on our blog early in the new year. 

Providers:

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

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 

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

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

Patients:

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

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

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

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

Time to Fight Horrors of Healthcare Costs by Taking Charge of Teaching Value

This Halloween, several creative costumes have emerged from the zingers of the Presidential debates – Big Bird costumes are selling out like hotcakes. For a more do it yourself look, here’s a recipe for Binders full of women.  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.  

As we head into the election, patients are increasingly being terrorized by runaway healthcare costs.  Americans outspend our peers two to one and still seem to be worse off. We overtest and overtreat to the point of absurdity.   According to a recent report, “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.”  The causes are multifactorial 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.

Experts in health professions education and economics have lamented the poor state of education on healthcare costs.  Over 60% of U.S. medical graduates describe their medical economics training as “inadequate.”  Not only are medical trainees unaware 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.  More recently, Medicare, the largest funder of residency training in the United States, is concerned that we are not producing the physicians to practice cost-conscious medicine in an era of diminished resources.  

We have been scared in the dark too long and this Halloween the time has come to Take Charge.

Join us now at http://teachingvalue.org/takecharge

About Teaching Value: the Costs of Care Teaching Value Project is an initiative of Costs of Care that is funded by the ABIM Foundation.  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.

Thinking through the Cost of Childbirth

Dr. Lauren Demosthenes is an assistant professor of clinical ob/gyn at the University of South Carolina – Greenville.

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.

Well…

What if this was her scenario?

Doctor:  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?

Patient:  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.

Doctor:  That’s great.  I’ll see you in the morning on the labor floor.

Next day :  the Labor and Delivery goes well and a healthy baby boy is born with apgars of 9/9.

Doctor:  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.

Patient:  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.

Doctor:  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.

Patient: 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.

Doctor:  Sure, Mrs. Kim.  We’re here to provide the best care ever.

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.

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.

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.

Why Residents Are Vital To Successful High-Value Education Projects

Christopher Moriates, MD is a Clinical Instructor in the Division of Hospital Medicine at the University of California San 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. 

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.

Trust me, though, these broken systems are not unique to our medical center. Consider, the following analogies from the brand new Institute of Medicine report:

• “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.
• If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.
• 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.”

Yes, ridiculous, indeed.

I have been out of residency now for exactly 87 days, and everything has changed. A new computer system has been implemented at our hospital and a whole new crop of interns - like Magellan chartering the Atlantic to the Pacific for the first time - are boldly routing out their own new process maps for countless different scenarios.

As an attending, my new formula (thankfully) looks like this:

“Need ultrasound done -> Ask intern.”

I am already woefully out-of-touch.

My point is, if you want to know about all of the waste in the system, the crazy things that we do that don’t make any sense, the countless middlemen and non-value-added steps, and the overtreatment and excess testing that lead to harm for patients, 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!

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.

At a recent national meeting, the question was raised by a medical educator, “But how do we try to implement “Choosing Wisely” or “Lean” initiatives when we have trainees at our medical center?”

The question should not suggest how do we achieve these goals despite trainees, but rather how do we do this with trainees. No, take it even a step further. How do we get our trainees to show us how to best incorporate a “Choosing Wisely” philosophy?

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 “opened up Pandora’s box” 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.

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 repeat blood cultures within 72 hours 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.

So, what can departments and residency programs do to help facilitate residents’ involvement in these sorts of projects?

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.

2. We can do what Dr. Talmadge King, 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.

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.

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.

 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 Sir William Osler: “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).”

More is Not Always Better

Dr. Robert Dickman is the founding Jaharis Chair of Family Medicine at Tufts University School of Medicine

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.

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 Academic Health Center (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.

Over the years, I have been honored to teach countless numbers of students and residents.  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.

I know I’m not alone but sometimes it really does feel like it. The misuse of resources continues unabated. Many years ago I wrote an article decrying the routine use of skull films 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%!  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

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  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.   Unless we are prepared to spend 50% of our GNP on health care, our present system is simply not sustainable.

While it is not hard to define the “problem” solutions are much more challenging. We can (and  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.

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  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.

Costs of Care Essay Contest 2012: Stories from Patients and their Caregivers Uncover Opportunities to Improve Healthcare Value

Neel Shah, MD is the Executive Director of Costs of Care and a chief resident in obstetrics and gynecology based at Harvard Medical School.

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 Costs of Care Essay Contest, we have collected hundreds of anecdotes from all over the country that are filled with lessons learned.

Some stories describe all too common medical oversights. Renee Lux, a patient from Connecticut wrote to us about an unnecessary CT scan 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 $100 budget.

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 New England Journal of Medicine and even the Institute of Medicine. This effort has been buoyed by the success of the ABIM Foundation’s Choosing Wisely Campaign, and several other notable initiatives aimed at getting caregivers to examine their own role in healthcare spending.

That is why this year we’re running the contest again.

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.

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 contest@costsofcare.org no later than November 15, 2012.

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.