January 25, 2012 Leave a comment
A recent article and accompanying editorial from the Annals of Internal Medicine covered the topic of value and cost in healthcare. It was an interesting read because unlike most of the policy/pundits’ takes on the issue, it revolved around the physician’s role in addressing the challenge of high costs. As clinicians are at the point of care, the article specifically focused on the decision to order screenings and diagnostic tests.
There is a distinction between cost and value in medicine. High costs are not necessarily ‘bad,’ so long as they provide appropriate amount of benefit for the amount spent (think of it as a high ROI). This is the definition of value. In the article, the authors identified 37 procedures selected by a physician workgroup which “clinicians often use in a manner that does not reflect high-value, cost conscious care and does not adhere to currently available clinical guidelines.” In a phrase, evidence-based medicine (or depending on the political cycle, the death panel.)
Assume for a second that X is the number of tests ordered by a physician today, and Y are the number of those tests that are unnecessary. Where we ought to be heading then, is to maximize the value of “Y.” There are two parts to this: Physician behavior change, and system improvements.
- Physician Behavior Change: The article outlines three driving principles surrounding improving judgment related to ordering imaging or other diagnostic tests: Don’t test if the result won’t change patients’ outcomes. Don’t test if there’s low probability of a disease, because you raise the risk of a false-positive diagnosis. Don’t consider just the cost of the immediate procedure, but also the downstream associated costs. To some extent, these three principles all hinge on the availability of dependable, rigorously tested guidelines that physicians actually trust.
- System Improvements: But even if we ask doctors to get it right every single time, it won’t be enough to optimize the X-Y value equation. The editorial had an important point that doctors may sometimes order exams just because it’s easier than tracking down the old test. It’s important to see this as an area ripe for a health IT intervention. For example, a Humana study with the Wisconsin Health Information Exchange showed that ED Patients whose data was referenced on the HIE cost $29 less on average than their control counterparts. The savings came nearly entirely from reduced imaging and diagnostic costs.
Healthcare is one of the most complicated fields there is, and part of that is because of the miasma of stakeholders: Doctors, Nurses, patients, family members, administrators, vendors, payers, policymakers, just to name categories. With a huge problem like ballooning healthcare costs, it will truly take a village to work together. Overuse of imaging is a clear opportunity area: One CBO study has estimated that up to 5% of our nation’s GDP is wasted on redundant testing in healthcare. Identifying a specific problem like this, and then figuring out how to dovetail advancements in medical efficiency and evidence-based medicine with the promise of new but proven technology will be the path forward to lowering avoidable costs in our healthcare system without compromising the quality of care and level of patient safety.