10/21/2013 Disclosures First, Do No (Financial) Harm • I do not have any relevant financial Christopher Moriates, MD relationships or commercial interests to disclose UCSF Division of Hospital Medicine Keynote Address, Primary Care Medicine October 30, 2013 CMoriates@medicine.ucsf.edu Twitter: @ChrisMoriates As an intern, I rotated through the Emergency Department… "To improve emergency room throughput we've replaced the front door with a CT scanner." Cartoon from ACP Internist Weekly Caption Contest 7/3/2012. Caption by Brett Montgomery, MD, from Richmond, Va 1
10/21/2013 Why Do We Do This? How much does this cost? Are We Treating The Patient In Front of Us? Illustration by Peter Arkle Cartoon by T. McCracken Bloomberg.com 7/ 11/ 11 www.mchumor.com Prices have been traditionally hidden Today’s Agenda from physicians and the public… • Why Physicians (Should) Care About Healthcare Costs • How Are We Teaching Physicians? – The UCSF Cost Awareness curriculum – An example case presentation • How Do You Operationalize These Ideals at the Bedside? – Highlight an example High ‐ Value Care Project • Conclusions Image from: Wired Magazine, 2012 2
10/21/2013 Why show physicians the costs? • It is part of physicians’ professional responsibility to use healthcare resources judiciously • Physicians lack basic understanding of healthcare costs and value -- they need to be trained about Slide showing % of GDP goes here? healthcare costs • Astounding amount of healthcare waste and “unnecessary testing” • It is important to the patient in front of us It Is About The Patient In Front of Us! An Uninsured Patient’s Perspective Side ‐ Effects May Include: Financial Ruin • Medical bills are the leading cause for personal bankruptcy in the United States • >75% were insured! • More Americans than ever before are now on High ‐ Deductible Insurance plans Himmelstein DU, Warren E, Thorne D, Woolhandler S. MarketWatch: Illness And Injury As Contributors To Bankruptcy. Health Affairs , no.W5(63), 2005. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009;122(8):741–6. Clip courtesy of This American Life from WBEZ Chicago 3
10/21/2013 It is About the Patient In Front of Us: Putting Off Care Because of Cost Percent who say they or another family member living in their household have done each of the following because of the cost: Relied on home remedies or over-the-counter drugs 38% instead of going to see a doctor 35% Skipped dental care or checkups Put off or postponed getting health care needed 29% 24% Not filled a prescription for a medicine Skipped a recommended medical test or treatment 25% 16% Cut pills in half or skipped doses of medicine Had problems getting mental health care 8% ‘ Yes ’ to any of the above 58% Source: Kaiser Family Foundation Health Tracking Poll (conducted May 8-14, 2012). Two separate motivations to consider Your Patients Are Reading This costs: 1. Macroeconomic resource stewardship 2. Financial safety of the patient in front of us 1 Screenshot from The Daily Show, 3/13/13 1. Moriates, Shah, Arora. First, Do No (Financial) Harm. JAMA, 2013 4
10/21/2013 The Sweet Spot: Where these two Generic Drugs motivations align • Approximately 4 of 10 physicians report they “sometimes or often” prescribe brand ‐ name drugs when a generic is available Good Good – “Acquiescing to patient demands” for for – Certain physician ‐ industry relationships were Society Individuals significantly associated with prescribing brand ‐ name drugs For example: Generic Drugs References: Cambell EG, Pham-Kanter G, Vogeli C, Iezzoni LI. JAMA Internal Medicine 2013; 173(3):237-239 Shrank WH, Liberman JN, Fischer MA, et all. Ann Pharmacother. 2011;45(1):31-38 Sources of $750B of Waste and Excess The Case of Statins in Healthcare • 8 statins currently on the market: 5 are available as generics • In 2011, fewer prescriptions for generic Simvastatin written than for Lipitor (Pfizer) • U.S. Primary Care physicians’ use of branded statins results in $5.8 Billion excess annual spending Atorvastatin References: Green JB, Ross JS, Jackevicius CA, et al. JAMA Int Med 2013, 173(3):229-232 IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. 5
10/21/2013 Patient Presentation – Mr. P The Patient In Front of You… • 45 year old man with 2 weeks of low back pain: You look at your schedule and see that – Aching with intermittent sharp pain, originating in lower spine your next patient is – Radiating to the left and right of his spine coming in with a – Worse with bending and standing, and after lying down for complaint of… long periods – Denies radiation to the legs, weakness, numbness, bowel or bladder incontinence, or any other neurological symptoms. LOW BACK PAIN – Improves with ice, and heat packs. He has taken Tylenol 350 mg PO twice a day x 5 days with limited improvement Patient Presentation (Continued) Vitals: Normal Back Exam : • Normal visual appearance • Tender over L4 ‐ L5 spinus processes, and adjacent muscles • No muscular spasm Some physicians may be resigned to a reality that • Limited motion in all 6 plains, financial adverse effects are a known and unavoidable secondary to pain harm of medical care. Neuro Exam: However, the same argument had been made previously • Strength: 5/5 throughout • Sensation: Normal light touch about central line infections, yet recent data highlight • Reflexes: 2+ symmetric at Pateller, that central line infections are almost universally ankle. avoidable through specific actions of physicians. • Gait: Normal. Able to walk tandom, tip toes, and heals 6
10/21/2013 Step 1: Step 2: Screen for Financial Harm Adopt a Universal Approach “Are you worried about how your medical care “Even though your insurance will cover it, I don’t will be paid for?” think that back imaging will help us. Most back pain like yours gets better on its own within 4 ‐ 6 weeks. “Are you having trouble paying for your medications at home?” The risks of radiation and the high cost outweigh any possible benefits. What were you hoping to find out with a scan?” Moriates, Shah, Arora. “First Do No (Financial) Harm.” JAMA, August 2013 Moriates, Shah, Arora. “First Do No (Financial) Harm.” JAMA, August 2013 Step 3: Step 4: Understand financial ramifications and Optimize care plans for individual patients value of recommendations “Your insurance will not cover physical therapy, but you could go to your local “Physical therapy has been shown to be Yoga class if you want for much beneficial in some back pain cases like cheaper. yours if the pain lasts more than 4 weeks. Yoga has also been shown to be helpful I could refer you to physical therapy if you for low back pain. are interested, but it may not be covered by your insurance and would likely cost you Do you think that you would want up to a couple hundred dollars out ‐ of ‐ to try that?” pocket. Would that be ok with you?...” Moriates, Shah, Arora. “First Do No (Financial) Harm.” JAMA, August 2013 Moriates, Shah, Arora. “First Do No (Financial) Harm.” JAMA, August 2013 7
10/21/2013 Previously widely ignored in medical What We Are Up Against… training: “The reasons for this silence are historical, philosophical, structural, and cultural. ...Combating such forces is a tall order, but I believe that medical educators have an obligation to address cost.” - Dr Molly Cooke (2010) Reference: Cooke M. Cost consciousness in patient care ‐‐ what is medical education's responsibility? N Engl J Med 2010;362:1253 ‐ 5 : Video: “Overrun with Overuse, Part 2” Teaching Value Project, Costs of Care, 2013 8
10/21/2013 Process: How the curriculum is delivered Introduction to the Introduction UCSF Cost Awareness Curriculum “Core” topic and case assigned Interns divide into two groups Guideline Review Case Analysis • Review literature • Review recent case from our institution • Find evidence based best ‐ practice • Analyze hospital bill, and clinical chart to guidelines evaluate care provided • Suggest cost effective workups • Reflect on our own clinical behaviors Case review debrief Case based noon conference for ALL residents UCSFCost Awareness Curriculum: Providing “ Value ” in Health Care Evaluation • Pilot: 176 evaluations from 10 conferences • Highly relevant to their clinical practices (mean, 4.6 +/ ‐ 0.6 on a 5 ‐ point Likert scale; median, 5) • Likely to change their ordering behaviors Quality (mean, 4.3 +/ ‐ 0.7; median, 4) VALUE = Cost Moriates, et al. JAMA Int Med, 2013 9
10/21/2013 …the purpose of this Two residents’ curriculum is not to teach experience with the rationing health care ; it’s to curriculum: teach rational health care . By learning the fundamentals of evidence-based medicine , but keeping the best interests of the patient in Through modules detailing common admission diagnoses, mind , we’ve learned how to he emphasizes the principles of evidence-based medicine use the most current and provides information about associated costs… guidelines to provide individualized yet cost- effective care . http://www.nejm.org/doi/full/10.1056/NEJMp1205634 http://primarycareprogress.org/blogs/16/191 Resources for Training Physicians Example: (Abbreviated) Case Presentation from UCSF Cost Awareness Curriculum www.highvaluecarecurriculum.org Costs of Care / ABIMF “Teaching Value” Project Cost Awareness Curriculum www.teachingvalue.org JAMA Intern Med. 2013;173(4):308 ‐ 310 10
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