Medical educators: Take charge and help deflate medical bills

At a time when one in three Americans report difficulty paying medical bills, up to $750 billion is being spent on care that does not help patients become healthier. Although physicians are routinely required to manage expensive resources, traditional medical training offers few opportunities to learn how to deliver the highest quality care at the lowest possible cost. While the gap is glaring the problem is not new.

In 1975, the department of medicine at Charlotte Memorial Hospital initiated a system to monitor medical costs generated by house officers. In the Journal of Medical Education leaders of the Charlotte initiative described how simply being aware of how clinical decisions impact the costs of care could decrease inpatient length of stay by 21%. Over the last four decades there have been dozens of similar efforts to educate medical students and residents about opportunities to improve the value of care. Some interventions were simple like the one in Charlotte, and simply revealed the cost of routine tests to their trainees. Others provided more sophisticated didactics, interrogated medical records to give trainee-specific feedback on utilization, or creatively leveraged the hospital computer order-entry systems.

To date, the results from such efforts have been mixed. Steven Schroeder at UCSF famously described the “Failure of Physician Education as a Cost-containment Strategy” in a 1984 JAMA editorial. There are likely several reasons why past efforts may have had limited success in bridging the current gap in medical education. For one, the incentives for physicians to deliver high value care have seldom been well aligned with the patient or payer incentives to get the most bang for their buck. It is no coincidence that most of the published papers describing this type of education appear during cycles of prominent political debate on the need for healthcare reform. The ability of any successes to take root have seemed limited by the transience in political and professional will to make the healthcare system in the United States perform better.

Election cycles in the early 1970’s, 1980’s and 1990’s shared similar public mandates to make healthcare more affordable but progress occurred in small fits and starts. In 2010 a major step forward was taken in the passage of the Patient Protection and Affordable Care Act, catalyzing a sweeping response within the medical profession. The Institute of Medicine released an influential report cataloguing the opportunities for physicians to provide the “best care at lower cost”. The American College of Physicians wrote the need to reduce unnecessary care into their professional ethics manual and the ABIM Foundation recruited 21 medical specialties to create “top 5” lists of unnecessary tests.

Although previous medical educators were limited by the circumstances of the health system, this time around is very different. Patients and policymakers are united in demanding better value from us and the professional momentum to improve is tremendous. The opportunity for medical educators to offer ideas that have traction has never been better.

Whether you have implemented something in the past that is due for renewal, are working on something now that should be scaled, or simply have a bright idea for a future project, we want to hear about it. The Teaching Value and Choosing Wisely ® Competition opens up this week – send us a short abstract and we will collectively help rising generation of clinicians remove unnecessary care from their practice.

Neel Shah is a chief resident in obstetrics and gynecology at Massachusetts General Hospital and Brigham and Women’s Hospital in Boston, MA. He is also the founder and executive director of Costs of Care, a grant-funded 501c3 venture. Christopher Moriates is a clinical instructor in the division of hospital medicine at the University of California San Francisco.  Vineet Arora is an associate professor of medicine and assistant dean for scholarship and discovery at the University of Chicago Pritzker School of Medicine. She is also director of education initiatives at Costs of Care.

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  • Ian

    I agree that at the educational level there is some utility in teaching future doctors about cost effective medicine. Sometimes the simple adage of don’t order a test that won’t change what you would do is even helpful. That being said I don’t think that training individuals who have little impact on the future costs of the actual testing which is what is going to make a dramatic difference. In addition, even though it feels like beating a dead horse, reduced testing will open physicians to increased liabiilty.

    Yes the case can be made that this physician didn’t take an adequate history, that being said I suspect his response, and the response of his colleagues is now to order a UA on all patients who come for that procedure regardless of how they fill out the medical history form.

    Physician overtesting (which I agree does contribute) likely dwarfs the costs of healthcare driven by other factors that go into the costs of testing. See recent Time magazine article on the subject .,9171,2136864,00.html

    One of the drivers of healthcare is the expansion of large hospitals, and large hospital corporations who then use their economic weight to negotiate for higher prices with insurance companies. In addition to that these hospitals and hospital clinics can charge facility fees in addition to the standard charges for testing. Places like The Massachusetts General Hospital and Brigham and Women’s Hospital, University of Chicago Pritzker School of Medicine, and the associated hospitals with The University of California San Francisco all can charge these facility fees. While I don’t have any cost data for your facilities, I can say that a particular ultrasound in my office costs between $100-120 and the exact same ultrasound down the road costs $400-600 because of facility fees. With this degree of pay disparity it is very difficult for indpendent doctors offices to stay open. Just ask any cardiologist who five years ago had an independent practice that now works for a hospital.

    Independent doctors going bankrupt.

    There are very few who would argue that the status quo is sustainable but one thing that is occuring because of government mandates (not just Obamacare) is the centralization of healthcare. EMR purchases, mandates, and encouragement of medical homes are going to make things more expensive than less expensive when independent doctors go bankrupt or choose to join large hospitals who then charge these fees and use their near monopolistic status to negotiate higher prices. There is even good data that EMR’s don’t save any money and actually make it easier for doctors to bill higher levels and make more money on each visit.

    There is good data that medical homes are improving care, but there is little data that medical homes are reducing costs. (10% improvement 1% cost savings)

    For the first time ever more new physicians are joining large hospital groups or hospital corporations. As more physicians join these institutions where their ultimate boss is some beancounter more interested in the bottom line than actual patient care I predict that the costs of testing, and healthcare costs in general are going to increase. I have to admit I’m not optimistic about the future of healthcare in this country as I see the end game one of four options in the order I find the most likely.
    1.) Not changing much (like Clinton in the 1990′s which isn’t sustainable). This is probably not a longterm outcome secondary to costs but in the short term is probably the most likely (3-5 years if ACO’s fail).
    2.) Going the route of Walmart (big corporations, bottom dollar the most important, customer, employee, and quality be damned). Your “healthcare provider” will be an employee of some mega or regional monopolistic corporation.
    3.) Basically the DMV writ large. This should not be taken as a diatribe against all more nationalized heatlh systems as some are thought to be quite effective (New Zealand, Switzerland etc.) but the US government can’t even run the VA program in a coherent, cost effective, quality manner.
    4.) The country takes a more free market approach. Price transparency, insurance portability, and competition (see $100 ultrasound vs. $400 ultrasound), helps reduce the costs of healthcare.

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