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(c) Costs of Care 2013
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All doctors should understand how the decisions they make impact what patients pay.
© Copyright. All Rights Reserved. Cost of Care.
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.
• Some or all of the information contained herein may be protected by patent numbers
• All other trademarks are owned by their respective owners