Physicians are the building blocks of value-based care, yet the cumulative human and financial cost of our decisions are mostly hidden from us. Instead, our reality is analogous to being on a diet and a budget at a restaurant that doesn’t put prices or calorie counts on the menu.
We need and want cost transparency. A survey from Deloitte University discovered cost is a part of the information puzzle physicians find most valuable but have the least access to. Looking at seven types of data, physicians considered cost data the third most important behind clinical outcomes and patient experience, yet it is the least available out of all of the data.
In this volatile health care environment, we’re required to play a pivotal role in cost containment and cost reduction, and we should be. Physicians are best equipped to play the decision-maker, synthesizing cost data, efficacy and patient advocacy. We need to be informed about cost data and iatrogenic risk, so we can become clinician-stewards — thus propagating value-based decision making and standardized quality care across our organizations.
The other day I saw a 57-year-old lady in the hospital with abnormal liver tests and reviewed her CT scan which showed a possible mass in the head of the pancreas. She needs an endoscopic ultrasound as the next step, as there was no obvious metastatic disease. Ordering a CA 19-9 blood test sounds like something I could do, but it doesn’t change the plan whether elevated or not. When you realize it is a $170 test and a 5-milliliter blood draw, you begin to think twice. In fact, you realize that you are not compromising care by not ordering it. Indeed, you are saving the patient a blood stick, and saving the hospital $170.
These “little” decisions add up. Saving $170 per admission means $6,800,000 per year in savings to a larger hospital. It’s a win-win for the patient and the health system.
Physicians do not compromise care based on cost data, but I’d argue that payers do. Why were hepatitis C drugs restricted from patients with active hepatitis C? Why did I have to prove the patient almost had cirrhosis prior to getting the medication approved? If you have an active, transmittable infection of the liver that is dangerous, how can we justify withholding a treatment with a 97 percent cure rate?
Many studies have shown that physicians make better choices when presented with the financial cost and potential risks of medications, labs and radiology tests when inside the EMR. The latter is crucial as technologies must be front-facing but not annoying to clinicians. Research has also documented the lack of correlation between health care spending and health care quality at both the national and regional levels, and even compared variation in spending among the same type of physician in the same hospital. In the end, all reached the same conclusion that higher-spending does not achieve better outcomes.
The larger problem is that our overutilization has consequences for the patient. A Choosing Wisely study from Washington state found that more than 45 percent of the health care services examined were determined to be low value (likely wasteful or wasteful). A survey of physicians revealed that 22 percent of medicines and 25 percent of tests are unnecessary.
I’ll never forget rounding on a patient years ago being consulted for nausea. When I was asked to perform an endoscopy, I reviewed the MAR and saw the patient was on 27 medications including metronidazole. This patient has succumbed to the therapeutic cascade when over testing and over treating leaves a patient suffering from iatrogenesis. Discontinuing metronidazole IV saved the patient from an endoscopy and the hospital from the cost of an intravenous medication, in addition to many other discontinued medications.
Patients are now responsible for a greater share of their health care costs. As providers of health care, we have the responsibility to reduce costs for our patients. How can we do this without cost and iatrogenic risk knowledge at the point-of-care? Patients simply do not have the expertise to make decisions about their care based on cost, but many patients have told me over the years that they value my knowledge of testing and medication costs. The movement towards price transparency must be concurrent for providers and patients.
While medicine’s digital transformation has been painful for us at times and is still a work in progress, there is real evidence to support that it will give us what we need to positively change the way we calculate quality of care and the risks of treatment. We need to be empowered to be not only efficient clinicians but good stewards of resources. If we operate at this efficiency mindset, we can work together to save millions of dollars. Some of us are already operating this way when exposed to this information. Exposing utilization review committees and those in administrative capacities only is missing the power of physician-facing workflow information. Isn’t that when we need it the most?
Mukul Mehra is founder, IllumiCare.
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