The Letterman Approach to Cost Awareness

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. 

Who doesn’t love a Top 10 list? Creating them is an art form.  So when it was formally proposed by Dr. Brody in 2010 in the NEJM that each specialty create their own “Top 5 list” of unnecessary care, it seemed like a straightforward – if not downright provocative – suggestion.

“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.

And yet, thus far the only groups that have seemed to have taken him up on the suggestion have been the primary care specialties of Internal Medicine, Family Medicine and Pediatrics - notably amongst the least compensated fields in health care.

 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.”

Not to say that there hasn’t been some progress. The ABIM Foundation has indeed put together an impressive list of organizations participating in their “Choosing Wisely” campaign. They also have begun to be instrumental in funding projects towards this goal. Costs of Carehas highlighted far-reaching areas of non-value-based care, including a recent thoughtful essay about robotic surgery. We must now consolidate on these small gains and move this forward across all specialties in medicine.

It is worth noting that one of our first steps in creating our curriculum at UCSF 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). 

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.  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.

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.

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.

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.

A Question of Worth

Dr. Eijean Wu is a gynecologic oncology fellow at the University of Southern California Medical Center, and was a finalist in the 2011 Costs of Care Essay Contest.

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.

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.

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 futile.” 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.”

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.

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.

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.

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.

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.

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.

The Bottom Line: What is good for shareholders may not be good for patients

This post was written by Dr. Kelly Wright, a minimally invasive gynecologic surgery fellow in the Boston area.

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.

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.

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.

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.

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.

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?

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.

In fact, researchers from Johns Hopkins found that hospital websites, using manufacturer-provided content, misled patients with clinical claims that have not been substantiated (1). 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.

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 (2) and hysterectomy for endometrial cancer (3). For some procedures, including benign hysterectomy, sacrocolpopexy (4), and myomectomy (5), 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 (6). In addition, studies show that robotic-assisted surgery is consistently $1600-$3000 more than conventional laparoscopy or open surgery (7,8). 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.

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 (9). 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.

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.