By: Nishant Pandya, SKMC Class of 2019
The health care system steadily faces increasing costs. Under its current trajectory, healthcare spending is projected to account for nearly 20% (approximately $5.5 Trillion) of the US GDP. $700 billion of this money is considered avoidable and unnecessary, including $325 billion of unwarranted use, $100 billion of provider inefficiency, and $50 billion of poor care coordination (1). While unfortunately there is no silver bullet for this challenge, the health care system must attempt to reduce costs without compromising the quality of patient care. Without an unexpected new revenue source on the horizon, many healthcare leaders have started prioritizing high value care to address this issue (2). The concept is straightforward: for each dollar spent, healthcare teams are to focus on achieving the greatest health outcome. However, the challenge lies in developing this mindset in practicing health care professionals and medical students (2,3).
Before implementing its High Value Care Training, the UNC Pediatrics Department Needs Assessment found that majority of the teaching faculty and residents did not feel confident in their abilities to deliver high value care and few had received any relevant instruction in the past. In hopes to bring change, the department used case base learning and guided lectures in a 5 part series to teach high value care through understanding benefits and harms, decreasing low benefit interventions, choosing high benefit interventions, customizing care according to patient values, and identifying system level opportunities to improve outcomes (5).
In one case study, the participants considered how to create a workup including tests for a patient with suspected pulmonary embolism. The group collectively ordered nine different tests, notably CT angiography, which costs $294.40 and D-Dimer assay which cost $65.88. A follow-up study analyzed the 22 CT angiograms that were ordered to “rule-out” pulmonary embolism (PE). For each patient, health records were provided to calculate their Wells’ Score, a probability scoring criteria used to diagnose likeliness of PE due to deep vein thrombosis. The calculated score indicates whether a patient is at high, moderate, or low likelihood for PE. The diagnostic algorithm advises high probability patients should have CT angiography performed while low probability patients should have a D-dimer assay performed (1).
Of the 22 CT angiograms that had been ordered, only 2 patients had PE. From the 20 other patients, 18 of those patients scored low likelihood on the Wells Score. Higher cost CT Angiography was unwisely ordered for patients whose risk for PE could have been equally measured by a lower cost D-Dimer assay. This case study hoped to highlight the overuse of imagining without initially checking pre-test probability and alternate low cost ways to rule out pulmonary embolism in patients (1).
While the training guided physicians through numerous “real-life” scenarios, participants admitted there would be challenges towards clinical implementation. They most frequently expressed difficulty changing habits, unawareness of every cost, and lack of support and instruction from administration (5). Even after the training, structural barriers exist that present challenges to changing the way practicing physicians approach their decision making by encouraging change at this stage in their career.
With this feedback in mind, the evidence points to the importance of introducing value based health care training early on in medical education. In 2012, the AAMC adopted the Do No Harm Project created at the University of Colorado. This initiative sought to develop clinical vignettes written by physicians to humanize concepts of medical overuse, over diagnosis, downstream harms and challenge the “more healthcare is better” culture (6). Two anesthesiologists from Beth Israel Deaconess Medical Center studied over 73,000 low-risk surgeries and focused on pre-operative tests ordered to look for potential imaging overuse. The study found chest x-rays (CXR) were regularly ordered to assess risk for pulmonary complications. However, they found pre-operative CXRs rarely contained unexpected findings that would not be available in the patient’s medical history and physical exam. Furthermore, despite 20% of CXRs being abnormal, the imaging only influenced operative management in 3% of cases (6). This unnecessary imagining order added roughly $200-400 to the health care cost and rarely improved the patient outcome quality. This study stressed the importance to use all available sources of information and order tests wisely.
The conversation, however, is not one-sided. There is concern towards the increased focus medical students receive towards high value care. Johns Hopkins Medical Ethics Department believes that the welfare of the patient must remain the primary focus of the medical profession and overemphasizing cost saving burdens the risk of unintended consequences for the patient (7). For example, screening is an early detection tool that may allow for earlier treatment and potentially significantly reduced medical costs. All screening tests however are not equal. When a patient comes to a doctor with symptoms, a screening test offers a possibility of relief and explanation of an ailment. Screening asymptomatic healthy patients, however, is different. In 2012, the Clinical Journal of American Society of Nephrology faced this issue when exploring the merits of screening regularly for chronic kidney disease by regularly testing urine protein levels. At the core was the struggle between marginal cost and marginal benefit. By testing asymptotic patients, there is an opportunity to improve long term outcomes and prevent further progression of disease. However, there is also risk of false-positive screening that would unduly cause the patient anxiety or the risk of false-negative screening that would wrongly reassure the patient of their health. As of 2014, the National Kidney Foundation suggested a compromise in recommending healthcare professionals test asymptomatic patients who are at considered high risk (8). Debate still surrounds the merits of asymptomatic screening. It holds the potential to reduce healthcare costs and improve outcomes, but the screening itself may ignore hidden costs that burden the patient without full guarantee of benefit.
The Johns Hopkins Ethics Department does not argue against the movement towards high value care nor is it complacent with where healthcare stands today. There is clear need to reduce costs, but the approach towards accomplishing this without harming patient care is its priority. Ideally, Hopkins Ethics Department suggests putting greater emphasis towards teaching students to communicate costs of healthcare initially while introducing more complex concepts of value much later in training. This hopefully ensures a distinction that high value care is not synonymous with low cost care.
I understand the long term benefit of introducing students to high value care early in training, but I share the ethical concerns mentioned above. Ultimately, physicians are asked to uphold the Hippocratic Oath and care for patients. Medical education is fast paced and voluminous with the goal to ensure students meet a set of academic competencies. In its current structure, medical education often leaves insufficient time to properly introduce and teach important concepts, such as high value care. While vignettes and seminars can teach high value care in theory, it is a greater challenge to expect students to seamlessly integrate potentially new concepts into a clinical mindset without long term exposure and comfort with high value care.
Considering the challenges and shortcomings associated with a condensed curriculum of high value care, I suggest a two part method to introduce students to this style of thinking in a meaningful and efficacious manner earlier in their medical careers. The end goal is to expose students to the financial aspect of medicine through a longitudinal curriculum during their preclinical years. Specifically, showing how each step of a hospitalization including tests, orders, and medications sum towards the final cost of healthcare. Peeling back the curtain and showing how the conversion of healthcare services into healthcare costs allows students to incorporate the concept of cost into their clinical mindsets before they hold direct patient care responsibilities. While the primary part of this idea requires greater structural change, an immediate option for medical schools to consider is requiring Introductory Economics as a prerequisite for admission. If high value care is one of the primary initiatives in medicine, then requiring incoming students to be familiar with cursory economics may be just as efficacious towards accomplishing this goal as the basic and social sciences medical schools already require.
With healthcare spending becoming an increasingly important topic, medical schools will have to find a way to integrate the fundamentals behind high value care earlier in the curriculum. Students should be introduced to economics topics like cost vs. benefit analyses and how they apply to healthcare before they are treating patients. However, the updated curriculum should not ignore the patient’s well-being at the risk of these economic principles. Schools must find a way to incorporate and balance these overlapping values and they must do so quickly.
- Swaroop, Bindu. “Introduction to High Value Care: Eliminating Healthcare Waste” Department of Medicine. University of California. 2016
- Rice, Lauren. "Health Care On a Budget: The Rise of Economic Dominance in Health Care Reform." (2012).
- Hillary, Wilson, et al. "Value based Healthcare." Advances in Management 9.1 (2016): 1.
- Porter, Michael E. "Value-based health care delivery." Annals of surgery 248.4 (2008): 503-509.
- Warthrop , Richard. "High Value Care In Practice and Education." The University of North Carolina. Pediatrics Department , 2014. Web. 28 Mar. 2017.
- Smetana, Gerald W. "The conundrum of unnecessary preoperative testing." JAMA internal medicine 175.8 (2015): 1359-1361.
- "Medical Ethicists Urge Caution in Teaching High-Value Care." Department of Ethics . Johns Hopkins University , 13 Dec. 2016. Web. 28 Mar. 2017.
- Kliger, Alan S. "Screening for CKD: A Pro and Con Debate." Clinical Journal of the American Society of Nephrology 9.11 (2014): 1987-1987.