Transcript ACP Advocacy

High Value, Cost-Conscious Care:
Wasting the Buck Stops Here
Donna E. Sweet, MD, AAHIVS, MACP
Professor of Medicine
The University of Kansas School of Medicine - Wichita
With great thanks to Dr. Steve Weinberger, MACP for the use of his slides
Conflict of Interest Disclosure
I have no financial
relationships with a
commercial entity producing
healthcare-related products
and/or services related to
this presentation.
Patient Presentation (part 1)
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50 year old male with 1 week history of
back pain similar to intermittent episodes
for past 20 years
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Initial work-up: MRI (required before
patient seen)  possible liver mass
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Next: abdominal ultrasound  nondiagnostic
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Then: repeat MRI  poor quality
Patient Presentation (part 2)
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Yet more: MRI #3  no liver mass, but
“something on the kidney”
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CT scan: liver and kidney normal
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Rx.: physical therapy  back pain
improved
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Cost of evaluation: $6200
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Additional cost: substantial anxiety!
What’s the diagnosis?
VOMIT
(Victim of Modern
Imaging
Technology)
Hayward R. BMJ. 2003; 326:1273.
Overriding issues in
health care
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Issue of the decade starting in 2000:
quality of care and patient safety
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Issue of the decade starting in 2010:
decreasing the cost of care
•
Jay Carney: “Every economist, whose
insights into this area are worth the paper on
which his or her PhD is printed, would tell you
that the principal driver, when it comes to
spending, of our deficits and debt, is health
care spending.”
Cost of Health Care
CMS, Office of the Actuary, National Health Statistics Group
Excess Cost Domain Estimates
IOM. The Healthcare Imperative, 2010.
It Is Our Ethical and Professional
Responsibility to Control Cost!
From Medical Professionalism in the New Millennium: A
Physician Charter (ABIM-F, ACP-F, EFIM)
“While meeting the needs of individual patients, physicians
are required to provide health care that is based on the wise
and cost-effective management of limited clinical
resources.”
“The physician’s professional responsibility for appropriate
allocation of resources requires scrupulous avoidance of
superfluous tests and procedures. The provision of
unnecessary services not only exposes one’s patients to
avoidable harm and expense but also diminishes the
resources available for others.”
Ann Intern Med. 2002; 136:243-246
But who do physicians feel should be
primarily responsible for controlling
health care costs?
Specific Group
Trial lawyers
Health insurance companies
Hospitals and health systems
Pharmaceutical and device
manufacturers
Patients
Practicing physicians
Tilburt, et al. JAMA. 2013;310(4):380-388.
Percentage
60%
59%
56%
56%
52%
36%
Conserving resources through rational
care does not mean rationing!
 Rationing: decisions are made about
the allocation of scarce medical
resources and who receives them,
leading to underuse of potentially
appropriate care
 Rational care: assuring that care is
clinically effective, thus avoiding
overuse or misuse of care that is
inappropriate
Ann Intern Med. 2011; 154:174-180
The ACP defines high-value,
cost-conscious care as
delivery of services that
provide benefits
commensurate with their
cost and that outweigh any
associated harm.
Questions Physicians Should Ask
Themselves Before Ordering Tests
Did the patient have this test previously?
 If so, what is the indication for repeating it? Is the result of a
repeated test likely to be substantively different from the last
result?
 If it was done recently elsewhere, can I get the result instead of
repeating the test?
Will the test result change my care of the
patient?
 What are the probability and potential adverse consequences of
a false positive result?
 Is the patient in potential danger over the short term if I do not
perform this test?
Questions Physicians Should Ask
Themselves Before Ordering Tests
Am I ordering the test primarily because the
patient wants it or to reassure the patient?
If so, have I discussed the above issues with the patient?
Are there other strategies to reassure the patient?
Current Philosophy at ACP
 Focus initially on the “low-hanging
fruit”: interventions with low or no
benefit, independent of cost
 Goal: reduce inappropriate care that
does not help (or even harms)
patients
 Ultimate outcomes: better patient
care, reduced cost
From Reinhardt blog, NY Times, 12/24/2010
Diagnostic Imaging Studies in Patients in Large
Integrated Health Care Systems: 1996-2010
Source: JAMA. 2012;307:2400-2409.
Why are diagnostic tests overused
and misused?
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Lack of guidance
or guidelines
Lack of knowledge
Patient
expectations
Inadequate time
Discomfort with
uncertainty
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Fear of malpractice
Habit
Erosion of physical
exam skills
Consultation
“thoroughness”
Personal gain
Overview of Goals for HVCCC
 Develop guidance for physicians about
appropriate use of care, focusing
initially on diagnostic testing
• Assemble and integrate evidence-based
and consensus-based recommendations
 Educate target audiences about areas
of overuse and misuse of care:
• Practicing clinicians
• Trainees (residents and medical students)
• Patients
Vehicles for disseminating high
value care resources
 Papers from ACP’s Clinical Guidelines
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Committee in Annals of Internal Medicine
ACP’s educational programs and
products, e.g., MKSAP, live courses
Development of resources for trainees
(with AAIM)
Patient education through ACP
Foundation
Collaboration with consumer and other
organizations
Ann Intern Med. 2011; 154:181-189
Identifies 37 clinical situations in which a
screening or diagnostic test does not reflect high
value care.
Ann Intern Med. 2012; 156:147-149.
Major Categories from “The Big List”
 Overuse/misuse of imaging studies
• Unnecessary CT and MR scans
• Unnecessary/inappropriate follow-up
studies
 Misapplication of screening studies
• Wrong population
• Incorrect timing/frequency
 Routine preoperative testing
Major Categories from “The Big List”
 Overuse/misuse of cardiac
diagnostic studies
• Coronary angiography
• Echocardiography
• Stress imaging tests
 Overused blood tests
 Unnecessary/overused monitoring
• Blood tests
• Pulmonary function tests
Creative marketing at work
Other National Initiatives
 National Physicians Alliance:
“Top 5” Campaign
 Archives of Internal Medicine:
“Less is More” series
 ABIM Foundation:
Wisely” Campaign
“Choosing
About Choosing Wisely®
First announced in
December 2011,
Choosing Wisely® is
part of a multi-year
effort led by the ABIM
Foundation to support
and engage
physicians in being
better stewards of
finite health care
resources.
Participating specialty
societies are working with
the ABIM Foundation and
Consumer Reports to share
the lists widely with their
members and convene
discussions about the
physician’s role in helping
patients make wise choices.
Learn more at
www.ChoosingWisely.org.
Choosing Wisely Partners –
Round 1
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ABIM Foundation (convener)
American Academy of Allergy, Asthma &
Immunology
American Academy of Family Physicians
American College of Cardiology
American College of Physicians
American College of Radiology
American Gastroenterological Association
American Society of Clinical Oncology
American Society of Nephrology
American Society of Nuclear Cardiology
Consumer Reports
ACP’s Choice of 5 Overused Items
for “Choosing Wisely” Campaign
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Screening exercise ECG in asymptomatic
individuals at low risk for coronary heart disease
Imaging studies in patients with non-specific low
back pain
Brain imaging studies (CT or MRI) for simple
syncope and a normal neurological examination
CT pulmonary angiogram as the first study in
patients with low pretest probability of venous
thromboembolism, rather than D-dimer
Preoperative chest radiography in the absence of
a clinical suspicion for intrathoracic pathology
The Society of General Internal Medicine (SGIM)
Five Things Physicians and Patients Should Question
1. Don't recommend daily home finger glucose testing in
patients with Type 2 diabetes mellitus not using insulin.
2. Don't perform routine general health checks for
asymptomatic adults.
3. Don't perform routine pre-operative testing before low-risk
surgical procedures.
4. Don't recommend cancer screening in adults with life
expectancy of less than 10 years.
5. Don't place, or leave in place, peripherally inserted central
catheters for patient or provider convenience.
American College of Cardiology
Five Things Physicians and Patients Should Question
1. Don’t perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without
cardiac symptoms unless high-risk markers are present.
2. Don’t perform annual stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic
patients.
3. Don’t perform stress cardiac imaging or advanced noninvasive imaging as a pre-operative assessment in patients
scheduled to undergo low-risk non-cardiac surgery.
American College of Cardiology
Five Things Physicians and Patients Should Question
4. Don’t perform echocardiography as routine follow-up for
mild, asymptomatic native valve disease in adult patients
with no change in signs or symptoms.
5. Don’t perform stenting of non-culprit lesions during
percutaneous coronary intervention (PCI) for uncomplicated
hemodynamically stable ST-segment elevation myocardial
infarction (STEMI).
American College of Radiology
Five Things Physicians and Patients Should Question
1. Don’t do imaging for uncomplicated headache.
2. Don’t image for suspected pulmonary embolism (PE)
without moderate or high pre-test probability
3. Avoid admission or preoperative chest x-rays for
ambulatory patients with unremarkable history and
physical exam.
4. Don’t do computed tomography (CT) for the evaluation
of suspected appendicitis in children until after
ultrasound has been considered as an option.
5. Don’t recommend follow-up imaging for clinically
inconsequential adnexal cysts.
American Psychiatric Association
Five Things Physicians and Patients Should Question
September 20, 2013 —
1. Don’t prescribe antipsychotic medications to patients for any
indication without appropriate initial evaluation and
appropriate ongoing monitoring
2. Don’t routinely prescribe two or more antipsychotic
medications concurrently
3. Don’t use antipsychotics as first choice to treat behavioral and
psychological symptoms of dementia
4. Don’t routinely prescribe antipsychotic medications as a firstline intervention for insomnia in adults
5. Don’t routinely prescribe antipsychotic medications as a firstline intervention for children and adolescents for any
diagnosis other than psychotic disorders
Do Physicians Agree That Health Care
is Overused?
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Survey of primary care physicians
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Perceived factors leading to overuse
42% believe patients in their own practice
are receiving too much care (vs. 6% who
say “too little”)
• Malpractice concerns: 76%
• Clinical performance measures: 52%
• Inadequate time to spend with patients:
40%
Arch Intern Med. 2011; 171:1582-1585
HVCCC and Residency
Training
 Habits start early in training →
need to focus on students,
residents, and fellows
 Joint initiative to develop HVCCC
program for residents: AAIM
and ACP
Are we educating residents?
(Dine CJ, et al. J Grad Med Educ. 2010; 2:175-180)
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37% of residents were provided some
feedback about their resource utilization;
20% reported receiving feedback regularly
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16% developed a concrete plan with their
attending physician for improving
resource utilization; 28% reported
receiving any corrective feedback
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63% reported having no idea about cost of
tests
Bringing Cost Consciousness into the
Training Environment
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Knowledge: understanding of what helps
patients vs. what is superfluous or even
harms patients
Approach: focus on appropriate care
rather than saving money
Culture: recognition that more ≠ better
Faculty development: trainees mimic
faculty behavior
Regulation: cost consciousness in
residency competency requirements
Overview of AAIM-ACP curriculum
(free download at www.highvaluecarecurriculum.org)
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Developed by 12 IM Programs (dept. chair,
program directors, and residents)
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Introduces and builds on a simple, step-wise
framework
 Ten one hour modules with a mix of didactic and
interactive teaching
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Small group activities involving actual cases
(inpt. and outpt.) and bills to engage learners
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A Facilitator’s Guide accompanies each module
to help faculty prepare
Ann Intern Med. 2012; 157:284-286.
Steps toward high value care
 Step one: Understand the benefits, harms, and relative
costs of the interventions that you are considering
 Step two: Decrease or eliminate the use of interventions
that provide no benefits and/or may be harmful
 Step three: Choose interventions and care settings that
maximize benefits, minimize harms, and reduce costs (using
comparative-effectiveness and cost-effectiveness data)
 Step four: Customize a care plan with the patient that
incorporates their values and addresses their concerns
 Step five: Identify system level opportunities to improve
outcomes, minimize harms, and reduce healthcare waste
Owens, et al. Ann Intern Med. 2011;154:174-180
Module topics
Topic
Cases
1
Introduction to healthcare
value
Pulmonary embolus;
deep venous
thrombosis
2
Healthcare waste, costs, and
over-ordering of tests
Headache; heart failure
3
Health insurance
Appendicitis;
osteomyelitis
4
Healthcare costs and payment Sports injury; asthma
models
5
Biostatistical concepts
Chest pain; primary
prevention CAD
Module topics
Topic
Cases
6
Screening and prevention
Periodic health
examination;
smoking cessation
7
Balancing benefits with harms and PSA screening;
costs
pneumonia
8
High value medication prescribing Seasonal allergies;
medication
reconciliation
9
Overcoming barriers to high value, Low back pain; upper
cost-conscious care
respiratory infection
10
Local quality improvement project
Ann Intern Med. 2011; 155:386-388
ACGME milestone relating to stewardship of resources
Source: http://www.acgmenas.org/assets/pdf/Milestones/InternalMedicineMilestones.pdf
Challenges for program directors
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Find space in a busy curriculum with
reduced duty hours to incorporate these
sessions
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Identify and develop faculty to teach these
topics and role model high-value costconscious care at the bedside
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Need to track this additional competency
in their trainees over time (ITE sub-score
on HVC; ABIM/ACGME milestones)
Challenges for faculty
 Ask appropriate questions at the point of care,
e.g.,
• Did the patient have this test previously?
• Will the results of this test change the care of the
•
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patient?
Was it the most appropriate and cost-effective test to
order?
What is the probability and what are the potential
adverse consequences of a false positive result?
 Observe and provide feedback to trainees on
their provision of high value care
Tough additional challenges in
controlling costs
 End of life care
 Physician financial conflict of
interest
 Defensive medicine
 Over-pricing
 Price transparency
 Decreasing hospitalization and ER
utilization
Is This Test Overpriced?
The Bottom Line
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Health care costs are unsustainable
Nearly 1/3 of health care costs are wasted
Physicians have control over a significant
component of these wasted costs
 Current physician practice and training have not
focused on avoiding waste
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The culture of residency training must change to
assure cost-consciousness
 Avoiding overuse and misuse must become a
core value and competency for residents
SOLUTION
Do you recommend daily home
finger glucose testing in
patients with Type 2 diabetes
mellitus not using insulin?
Do you do imaging for
uncomplicated headache?
When do you image?
Do you do imaging studies in
patients with non-specific low
back pain?
Is it overused?
Do you do preoperative
chest X-rays?
How many times a week do you
do them?
Do you use glucosamine and
chondroitin to treat patients
with symptomatic
osteoarthritis of the knee?