Addressing This Decade's Primary Challenge for Medical Training

Patrick C Alguire, MD, FACPSenior Vice President, EducationAmerican College of Physicians

Overview

Why is cost consciousness important?

Examples of current efforts to control cost

What is the current status of cost consciousness during training?

What might/should be done?

Overriding Issues in Health Care

Issue of the decade starting in 2000: quality of care and patient safety

Issue of the decade starting in 2010: decreasing the cost of care

Cost of Health Care

CMS, Office of the Actuary, National Health Statistics Group

Excess Cost Domain Estimates

IOM. The Healthcare Imperative, 2010.

Why are Diagnostic Tests Overused and Misused?

Lack of guidance or guidelines

Lack of knowledge

Patient expectations

Inadequate time

Discomfort with uncertainty

Insecurity about clinical skills

Discontinuity of care

Fear of malpractice

Habit

Personal gain

Overview of Goals for the ACP HVC Initiative Develop guidance for physicians

about appropriate use of care, focusing initially on diagnostic testing• Assemble and integrate evidence-based

and consensus-based recommendations Educate target audiences about areas

of overuse and misuse of care:• Practicing clinicians• Trainees (students, residents, fellows)• Patients

Ann Intern Med. 2011; 154:174-180

Ann Intern Med. 2012; 156:147-149.

Identifies 37 clinical situations in which a screening or diagnostic test does not reflect high value care.

Other National Initiatives

National Physicians Alliance: “Top 5” Campaign

ABIM Foundation: “Choosing Wisely” Campaign

JAMA Internal Medicine (Arch Intern Med): “Less is More” series

Choosing Wisely Partners

ABIM Foundation (convener) American Academy of Allergy, Asthma &

Immunology American Academy of Family Physicians American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Clinical Oncology American Society of Nephrology American Society of Nuclear Cardiology Consumer Reports

What are the current program requirements re cost-consciousness?

Under:

IV.F.5.f) Systems-based Practice

Residents are expected to:

IV.A.5.f).(3) incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate

Are We Educating Residents?(From University of Pennsylvania)

37% of residents were provided some feedback about their resource utilization; 20% reported receiving feedback regularly

16% developed a concrete plan with their attending physician for improving resource utilization; 28% reported receiving any corrective feedback

63% reported having no idea about cost of tests

Source: JGME. 2010; 2:175

A Resident’s Perspective on Top 10 Reasons for Over-Ordering

1. How we’re taught (don’t consider cost)

2. Trying to do our best for the patient

3. Pre-emptive ordering

4. Covering all bases (more=better)

5. General lack of awareness (of cost)

6. Broader ignorance (costs are opaque)

7. Not realizing how much setting affects costs (e.g., ER)

8. Defensive medicine

9. Patient requests

10. Lack of oversight

Neel Shah. CommonHealth.wbur.org

Coming Your Way Soon!

ACGME is increasingly concerned about overuse/misuse of care

• How to strengthen current competencies to make programs accountable

ABIM is becoming more focused on stewardship of resources

• More Items in the certifying and MOC examinations

IM-ITE contains “high value care” subscore

Cost-Consciousness and Training

Habits start early in training → need to focus on students, residents, and fellows

Joint initiative to develop HVCCC program for residents: AAIM and ACP

Ann Intern Med. 2012; 157:284-286.

Curriculum Dissemination and Evaluation

Over 5200 individuals have accessed the curriculum to date

Approximately 16% of those accessing the curriculum are residents and students

Plan for feedback survey about the curriculum

Other metrics: resident survey; program director’s survey; high value care sub-score on the IM ITE

Challenge for Program Directors Focus on cost reduction and

minimizing overuse/misuse of diagnostic testing

Questions• Why did you order that test?

• Was it the most appropriate and cost-effective test to order?

• What are you going to do with the results?

• Will it change your management?”

The Bottom Line

Health care costs are unsustainable Nearly 1/3 of health care costs are wasted Physicians have control over a significant

component of these wasted costs Current physician practice and training

have not focused on avoiding waste The culture of training must change to

assure cost-consciousness and avoiding waste becomes a core value that residents understand and practice