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Posted by Ishani Ganguli February 28, 2013 11:15 AM
When I read Steven Brill’s epic takedown of health care costs in Time, my first reactions were sticker shock and outrage at the capricious ChargeMaster that has pushed so many Americans into bankruptcy. This was followed by unease: Did I really need to use that second square of gauze (priced at $77 a box, according to Brill) after placing that central venous catheter the other week?
As he dissects a series of medical bills and follows each line item to its source, Brill points the finger both at marked-up prices by manufacturers and hospital administrators stemming from our lack of price controls and at the quantity of line items (ie. the overuse of resources). Setting aside the critical need for payment reform and true price competition, doctors have a significant role to play in mitigating that second offense. To this end, we’re now meant to learn about medical costs as part of our medical training, though institutional norms and perverse incentives have made this challenging.
Brill’s article should be required reading for medical trainees (but let's face it, most of us take our reading material bullet-pointed and condensed into a pocket manual). In the meantime, third year internal medicine resident Chris Moriates has developed a clever way to help doctors navigate the murky world of health care costs that he published in this week's JAMA Internal Medicine.
Along with colleagues at the University of California, San Francisco (UCSF), Moriates put together an introductory lecture for interns on health care costs then asked them to study the case of a recently discharged UCSF hospital patient. The interns read about the patient's hospital course and examined his itemized hospital bill. They reviewed what evidence-based guidelines tell doctors to do, and what they commonly do instead, to diagnose and treat that patient's condition. They looked at the costs associated with each approach. For these lessons, Moriates and colleagues chose patients with medical problems like headaches and chest pain for which there is a lot of variability in how many tests and treatments doctors order. Each month, they also presented one of these cases at lunch conference to an audience of medical students, residents, and senior doctors.
I think this is a fantastic approach. It makes health care costs tangible for doctors and enforces the (albeit limited) means we have to control them by making a clear connection between the decisions we make and their line item consequences. Much like a hypothetical CVS ExtraCare card receipt, it also demonstrates quite satisfyingly the cost savings to be had by doing the right thing. Take the 45-year-old man who came in with low back pain and underwent an elaborate evaluation including blood tests, an X-ray, trials of medication, and an MRI for a sum total of $10,821. The guideline-dictated work-up, in contrast, would have cost $908, the UCSF team reported. On average, trainees and senior doctors at UCSF said they were quite likely to change their practice as a result of such case presentations.
The authors of the paper make a key point, one that we need to do a better job of advertising to our patients: this lesson for residents, and similar efforts like the American Board of Internal Medicine’s “Choosing Wisely” Campaign, is not about indiscriminate cost-cutting and withholding needed tests or treatments simply because they are pricey. This is about using resources judiciously. We should order that MRI when there’s reason to worry about cancer or a spinal infection, but not for a patient without the associated red flags. We can use that second square of gauze if we truly need to (and maybe carry our own supply from Amazon.com).
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