Physicians have an obligation to eliminate waste

Physicians and the public are urging doctors to bring cost into consideration at the bedside when ordering laboratory tests and imaging studies.  Although diagnostic testing represents an important component of the rising cost of medical care, asking what a test costs is the wrong question.

Cost-saving shouldn’t begin at the bedside, it should begin by training the next generation of doctors to think in terms of value; not bang-for-buck or potential yield of a study per dollar spent, but rather the clinical value. One right question, which academic attending physicians have asked trainees for decades is: “how will this test change your management?”  Every test ordered should include a pre-test assessment of the patient’s prior probability of disease (in terms of objective epidemiology and subjective features of the presentation) and the test’s intrinsic performance characteristics.  Some tests are “better” than others for ruling-in a given diagnosis, others for ruling-out.  Evidence-based diagnostic testing strategies provide valuable clinical data at a cost that patients and payers are willing to accept because the results of appropriate testing have an impact on outcomes that are important to patients.

We object to the discussion of the “cost of a test” being posed to healthcare providers in isolation.  Healthcare expenses have skyrocketed so far out of the everyday price range.  We cannot conceive of what a trillion dollars is (our healthcare expenditure), because it’s just too big a number.  Emphasizing a US dollar value is coercive, because we interpret the value as we would an expense out of our own pocket.  Indeed, one recent trial showed that a weekly flyer announcing “cost” to residents was sufficient to reduce daily lab utilization.  This is akin to reducing laboratory tests by sticking residents in the arm with a needle every time they ordered a blood test on a patient.

Furthermore, it is reductionist to assign a price tag to a routine lab test.  Are we referring to the cost to an individual patient (which would be variable based on their insurance—if they have insurance), the cost to the hospital laboratory, or the amount billed to a third party payer by CPT code?  In order to truly understand the expense of a lab test, we would need to account for the cost of the million dollar automated analyzer in the medical laboratory, the service contract with the manufacturer of this machine, the cost of reagents, and the salary of the technologist who operates it.  These are all bills that the hospital pays in order to allow us to provide patient care, a laundry list that comprises the “cost of doing business” like the hospital’s air conditioning, supply of 4×4 inch gauze pads, or the actual laundry.

As physicians our obligation to eliminate waste includes not just minimizing out-of-pocket expenses for our patients, but also stewarding responsible use of hospital or system-wide resources. Perceived cost should not deter the appropriateness of  “morning labs” any more than the cost of a blood pressure cuff should be taken into account when obtaining the 6 am vital signs.

However, a patient who has had stable bloodwork and has already clinically recovered from her pneumonia certainly does not need her blood drawn on the day of discharge. She doesn’t need it because it is a needle in her arm, it is a waste of the phlebotomist’s time, and it is a waste of the lab’s time to run it.  Sound, patient-oriented clinical judgments save money too.

Benjamin T. Galen is an internal medicine physician, and Christopher T. Erb is a pulmonary and critical care physician.

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  • Neel Shah

    excellent post – I believe cost-consciousness is necessary in many circumstances (when you are ordering of a menu with no prices it is easy to get the filet mignon every time), however knowing costs is not sufficient or even the end goal. Some tests and treatments are expensive and certainly worth it. As the authors point out, we need to provide patients with better value. Costs are one element of this. Appropriate use guidelines may be another. Understanding incentives to over utilize may be another. Agree that sound clinical judgements can save patient money too.

    • Kristy Sokoloski

      While some tests and treatments that are expensive may be certainly worth it to try and diagnose and treat said problem it is a problem for the patient to have those tests if they can’t pay the bill. Some patients that have insurance can’t afford the coinsurance and deductibles that must be met in order to have those tests and treatments done.

    • Scott M Stallings

      What about the fact that tort reform has not yet been addressed? If my ability to provide for my family could be taken away because I miss something because I was being cost conscious, I am not willing to take that risk

  • Ali Khan

    Excellent post. From the perspective of those of us in the physician community arguing for a stronger emphasis on cost-consciousness, the concept of value is paramount. Simply recognizing cost isn’t enough – it’s about recognizing when it’s appropriate to spend money in the patient’s best interest. As the authors note, value and clinical relevance are necessarily intertwined.

    I wonder, then, whether the authors’ concern over the discussion of “cost-consciousness” is really the byproduct of marketing/branding failure. When we all agree that value is what we seek to maximize – and when the cost-consciousness movement itself is built on value-maximization – but that message isn’t immediately clear to ground-level actors such as these two men, then we need to do a better job of framing the cost discussion for the general physician audience.

    So in summary, Jamie, I agree with you – and so do the cost-consciousness champions with which I work. We all agree on value – we just need to do a better job with framing the argument for it.

    • Neel Shah

      well said!

  • David Voran

    We should make that contract to do what we can to make healthcare less expensive for our patients. As we shift our reimbursement mechanisms from volume based to quality based this should really be a no brainer. Trouble is most of us are caught in a world where we haven’t reached critical mass in payers reimbursing on quality but still stuck on pay for volume. So in the short run cutting costs will take money out of our pockets but it’s something we should’ve been doing all along.

  • Dorothygreen

    It is probably not the physicians who are blogging on Kevin MD that are the biggest wasters – not just of an individual patient’s dollars but of Medicare dollars as well. And when Medicare dollars are being wasted we all pay.
    It’s still easy to do – given the ability for coding creep, of the new rules PCPs must follow, abuse of EMR. I hope the ACA can accomplish some change in this regard. As a Medicare recipent, having paid, at this point, far more than my fair share into the system than I will use (if I continue to follow a healthy diet, exercise, have a firm advanced directive and a family who will follow it), I do resent the waste by hospitals, physicians AND patients who choose not to take care of themselves (more tests, more care) or understand the futility of more than comfort measures when one’s quality of life is 0 and falling.
    The IOM report on waste does tnot take the individual’s contribution into the waste calculations but if they did, I would estimated it is about 1/2 of those dollars. So docs, there is plenty of blame to share.

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