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.

Video Webinars: Educating the Whole Community About Healthcare Cost Control

Abraham (Nick) Morse MD, MBA is currently Assistant Professor of Obstetrics and Gynecology at Harvard Medical School

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.

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.

In the spirit of full disclosure, I volunteer for GBIO in the role of physician advisor to the Health Care Team.

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.

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.

Both can be found on the THCI/GBIO web pages at:
http://thci.org/GBIO/welcome.aspx

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.