the challenge of considering costs while caring for patients

All doctors should understand how the decisions they make impact what patients pay.

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It must be done, but how?The Challenge of Considering Costs while Caring for Patients

Neel Shah, MD, MPPExecutive Director, Costs of Care

Chief Resident, Departments of Ob/GynMassachusetts General Hospital / Brigham & Women’s Hospital

May 18, 2013

Helping caregivers deflate medical bills

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Disclosures

Putting the Physician Charter into Practice Grant

“The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures”

- Medical Professionalism in the New Millenium: A Physician Charter, ABIM (2002)

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Changing Landscape

Patients

transparency

Policymakers

accountability

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Reimbursement Reform

fixed budget

fee-for-service

do more, make more

global payment

shared risk

efficiency metrics

Massachusetts to debut Medicare pay planPartners doctors to paid for total care, rather than piecemeal

Globe Staff | December 10, 2011

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Annual Contribution to Premiums (Family Coverage)

Kaiser Family Foundation, 2011.

Pre

miu

m C

ontr

ibut

ions

($

)

CAGR 10%

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Patient Affordability: MA

The Access Project, 2009

Insured non-elderly adults in MA reporting problems paying medical bills

medical debt rates unchanged

Urban Institute, MA Health Reform Survey, 2010

98% have insurance

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Insurance Benefit Transparency

“HHS Unveils Requirements for Consumer Insurance Labels”

Feb 9, 2012

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Consumer-directed Price Transparency

>30 states are considering or pursuing legislation to increase price transparency (Sinaiko and Rosenthal. Increased Price Transparency in Health Care. NEJM. March 2011)

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5-Strongly Agree

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Significantly More

Moderately More

Percent more influenced 57% 67%

© Copyright. All Rights Reserved. Cost of Care. 14Graham JD, Potyk D, Raimi E. Hospitalists' awareness of patient charges associated with inpatient care. J Hosp Med. 2010 May-Jun;5(5):295-7.

Illustration by Peter Arkle, Bloomberg.com 7/11/11

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The Problem

Organization for Economic Cooperation and Development http://stats.oecd.org

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The Problem

“We seem to have as much as $700 billion a year in health care tests and services that are unnecessary, that don't improve health outcomes, and that just add to costs ... ”

Peter Orszag, Director of the White House Office of Management & Budget. February 19th, 2009

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Are doctors being reckless?

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multiple stakeholders with different information

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doctors are trained to take care of the patient in front of us

The “system”

The bedside

… not to assume responsibility for populations

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Roadmap

✓

✓

✓

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April 2010, NEJM

Nov 2011, Acad Med

Sep 2011, Ann Intern Med

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The Congress should authorize the Secretary to change Medicare’s funding of graduate medical education (GME) to support the workforce skills needed in a delivery system that reduces cost growth while maintaining or improving quality.

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The indirect medical education (IME) payments above the empirically justified amount should be removed from the IME adjustment and that sum would be used to fund the new performance-based GME program. To allow time for the development of standards, the new performance-based GME program should begin in three years (October 2013).

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Hidden Curriculum

• imbalanced focus on identifying rare cases

• sins of omission > sins of commission

• misperception that considering cost is not aligned with patient interests

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Ten Reasons Trainees Knowingly Over-Order Tests

1. Pre-emptive ordering•Standard practice might be to order a relatively cheap screening test and then if it’s positive, order other expensive tests•Instead we sometimes just order everything at the same time so we don’t have to wait

2. Covering all bases•In medical culture, doing more is equated with being thorough. •If there are five possible conditions that may explain a patient’s symptoms, and it’s probably going to be one or two of them, we might order tests for all five conditions right away.

3. Not realizing how much setting affects costs •An MRI in an emergency room setting can be twice the cost of an MRI for an outpatient.

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“Taxonomy” of Cost-Consideration

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Ethical Motivation for Considering Costs

?

?

Good for patient

Good for society order test

Bad for patient

Bad for society don’t order test

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“Taxonomy” of Cost-Consideration

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“Taxonomy” of Cost-Consideration

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“Taxonomy” of Cost-Consideration

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Target the margin

serial ultrasoundsmode of hysterectomy

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Web-based Education: Teaching Value Project

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www.TeachingValue.org

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Teaching Value & Choosing Wisely ®

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Costs of Care Essay Contest

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“Less Is More” Teachable Moments:Trainee Perspectives – (Accepting articles now!)

• First author must be a trainee

• “Story from the frontlines” illustrating avoidable care

• “Teachable Moment” explaining the evidence

• Suggested total length: 600 words

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Medical Decision-Making

Safety

Efficacy Cost

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How much can we save?

$700 billion low value health care spending X

20% variable costs X

70% physician-driven component =

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moving from rationing to conservation

help bring environmentalism to health care

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Contact Us

www.CostsOfCare.org

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© Copyright 2012

• This publication is the property of Cost of Care, Inc. No part of this presentation may be reproduced, translated into another language or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written consent of Cost of Care, Inc.

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