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).”