Extreme couponing for medical residents?

As a society, we have to trust doctors to order the right types and amount of care, but doctors aren’t well-equipped to incorporate costs into their decision-making. One important reason for this is that we don’t know how to measure the true cost of delivering care, as Robert Kaplan and Michael Porter recently argued.

What are the knowledge, skills, and attitudes involved in cost-conscious care?  For one, a strong grasp of clinical medicine—knowing exactly which tests we need to answer the question at hand. Understanding patients’ contexts and personal preferences, and comfort with uncertainty: Is it worth putting this person through a battery of tests when an exact diagnosis may not change her prognosis or treatment plan? And of course, knowing how much tests and procedures actually cost.

So how do we make sure doctors-in-training are cost-conscious providers? Adding a seventh competency is a nice symbolic move, but we have to think carefully about what it would look like in action.

I worry that this regulatory step would lead residency programs to simply cram in a few lectures or feedback sessions on cost-conscious care. The solution won’t be found in such sessions, which we residents may or may not have the time to attend and would quickly forget when we returned to the hospital floor.

Instead, we need to incorporate the cost or value dimension of health care into residents’ daily work. This is a much harder task which requires a systems-wide commitment. We need to see the cost impact of each test or treatment that we order when we order it, or at least, the poor proxy of how much providers are reimbursed (at MGH, lab tests are listed with one or more dollar signs to approximate reimbursement price). We need to fold cost discussions into our morning rounds. We need to report to senior doctors who have a strong grasp of these issues and can enable good practices: ones who do not ask us to order a test purely “for academic purposes” but instead see an academic purpose in modeling the judicious use of health care resources.

It often takes more time to be cost-conscious - to comb through the daily blood tests already ordered for a patient and decide which ones he still needs, to follow up with a consulting specialist on her request for an MRI to decide if it is truly worthwhile. So we need incentives to do this - not necessarily a financial cut (this is a tricky calculation), but at least acknowledgement from our colleagues and supervisors that our efforts are meaningful.

Numerous conversations with residents at MGH and elsewhere have convinced me that by and large, we already appreciate the importance of cost-consciousness in health care. We just need the tools and the room to practice this way.