Short Takes On News & Events

Teaching Doctors About The Cost Of Care

By Jenny Gold

July 11th, 2012, 5:27 PM

All new doctors take the Hippocratic Oath, promising to care for their patients to the best of their abilities.

But what does that mean in terms of the cost of that care, when medical debt accounts for more than 60 percent of personal bankruptcies in the United States?

The fee-for-service payment system has long rewarded doctors financially for running more tests and doing more procedures, even though that can drive up costs for patients.

But as the country grapples with mounting health care costs and dwindling resources, physician organizations have started to look at how the everyday decisions made by doctors drive up the cost of care for patients. At least nine groups have even come up with lists of expensive tests and treatments that are commonly prescribed but are often not necessary.

Still, “the conversation has yet to change the way we’re trained to practice care,” write Drs. Lisa Rosenbaum and Daniela Lamas in a perspective piece published this week in The New England Journal of Medicine that looks at how medical schools are teaching (or choosing not to teach) the next generation of doctors about fiscally-responsible medicine.

“Is there a place for principles of cost-effectiveness in medical education? Or does introducing cost into our discussions threaten to destroy what remains of the patient-physician relationship?” the authors ask.

Medical schools, Rosenbaum and Lamas explain, traditionally train students by presenting them with a sick patient, and asking them how to proceed. A cough and fever, for example, could be a sign of pneumonia, but it could also mean pulmonary embolism, heart failure, or scores of different rare diseases. Inevitably, this leads to students recommending a battery of tests (and a mounting bill for their hypothetical patient), and leaves them with the lesson that resources are essentially unlimited.

A few medical schools, however, have started to impart a more nuanced perspective that “thinking about cost can actually improve care,” a message that may serve new doctors well in the changing world of accountable care organizations, pay-for-performance and value-based purchasing.

The University of California, San Francisco, for example, is using a curriculum for internal medicine residents that brings cost into the equation.

In one lesson, the young doctors evaluate the treatment given to a patient with a pulmonary embolism, focusing on the benefits and costs of each test and procedure. When the students finished making their recommendations, Rosenbaum and Lamas write, the hospital bill comes to $155,698, some of which would likely be shouldered by the patient, even if that patient is insured. The idea is not to skimp on necessary care, but rather to determine whether some of that spending was wasteful.

“The focus is not on limiting expensive care, but rather on the principles of evidence-based medicine,” they write. Efforts to teach about cost are spreading, and the American College of Physicians has been working to create a curriculum for medical schools. Residency programs are already required to teach doctors to “incorporate considerations of cost awareness and risk-benefit analysis” in caring for patients, according to the Accreditation Council for Graduate Medical Education, though not all programs comply.

And not everyone approves of training doctors to consider costs. Rosenbaum and Lamas cite Dr. Martin Samuels of Boston’s Brigham and Women’s Hospital, who “cautions that when physicians start weighing society’s needs as well as those of individual patients, they begin to lose the essence of what it means to be a doctor.” Some even question whether considering the costs to society instead of focusing on what’s best for the patient could potentially force doctors to violate their Hippocratic Oath.

But taking costs into account isn’t just about bending the cost curve for the country. It’s also about the crippling effects that medical debt can have on the lives of the one in three Americans who are struggling to pay their health care bills.

“Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment,” the authors write.

6 Responses to “Teaching Doctors About The Cost Of Care”

  1. Arthur Kim says:

    I welcome an article such as this to keep reminding various stakeholders in medical education including undergraduate medical education, graduate medical education and continuing medical education. As a Healthcare MBA student, I can attest that such medical education curriculum is not a matter of choice. It has become a matter of necessity. I have conducted an extensive survey of medical students, residents, and physicians in practice for their business acumen recently as my master thesis. The result is very interesting. Simply put, majority surveyees (over 70%) feel that their acumen and readiness to meet the future healthcare challenge is seriously inadequate. It is also interesting to observe that we are now begining to take this matter seriously. The opportunity is here. It is about time to do more definitive things.
    Arthur Kim, MD, FACS
    Instructor of Surgery, Tulane University School of Medicine

  2. Having worked alongside physicians for the past 20 years I must comment on something missing here. A big part of the “extra” testing and searching for zebras (uncommon diagnosis) is because of legal fright.
    I don’t feel doctors overtest because of their education, but rather their understanding of just how easy it is to be sued for anything “missed”.
    Reduce tort litigation and you will fix this problem.
    Matt Resinger FNP

  3. Pete says:

    Doctors care about cost? Fat chance! My PCP is still prescribing brand named medicines when a perfectly good generic is available. His answer when I suggest switching to the generic? He says, “I’m the doctor, not you! If you don’t like how I do things, then go see if you can find another primary care physician that takes new Medicare patients!” He’s told me many times that he can’t stand whining patients, especially whining Medicare patients. However, there’s hope for the future. There’s a hospital group in my area that’s planning to open up an Accountable Care Organization (ACO) once they get the green light to do so. Currently, this ACO is buying up small solo-doc practices in record numbers. When this ACO opens their doors for business, I’ll be the very first customer in line to sign up for their services. It’ll be a great day when I can dump my current greedy PCP.

  4. steve says:

    Being an optometrist in an ACO and 10 IPA’s I would suggest that you lower you expectations or at least Look before you leap before going to the ACO. The way your PCP handled your issue about wanting a lower cost generic, which I often get, was inappropriate to say the least. Every office should be patient centered not insurance or doctor centered. In an ACO the doctor really does not set the rules, an insurance company will deciede what care you need and which doctor you get to see. So IF the PCP in the ACO was like the one you are leaving or you are referred to the only specialist on the panel that you happen to not like or if the generic medication does not work for you and you would need a name brand, the ACO is going to limit those choices as well. At minimum look up which doctors are on the ACO and if that is going to be a good match for you. Check your current medications and see if they will be covered. Check the wait time and what it takes to get an authorization for current regular testing you may need and what the cost maybe. It maybe be a good match for you it may have some limitations but it most likely will not be as hopeful of an answer for you as you suggest. Just today i spent 30 mins explaining to a patient, after my staff spent and hour doing some work to get an authorization for just a regular eye exam and why certain parts were not covered. It is a daily occurrence and many patients have no idea what the insurance or ACO rules are for them to pay and you to be covered. They just assume its the doctors fault.

  5. Pete says:

    Unlike the old broken fee-for-service model, the ACO model will reward wellness and good outcomes. That is a profound and fundamental difference in the way health care is delivered. Today, providers are rewarded for volume. Nothing else! The more procedures they perform and the more medicines they prescribe, especially brand named medicines, the greater the financial reward. Healthy people are like owning a foreign car that runs forever and hardly needs maintenance. Mechanics don’t like cars that never break. Same is true with health care providers. In the fee-for-service model, providers don’t get wealthy if you are healthy. Providers want you as sick as possible as much as possible. A waiting room filled with sick people is a doctor’s dream, especially if the customers have fat wallets and are not Medicare or Medicaid patients. In the ACO model, an empty waiting room equals success. A patient base that’s healthy is success. In the ACO model, the provider gets the same set dollar amount per patient regardless of their health condition. What’s the incentive? Even a moron can figure it out. Keep the patient base a s healthy as possible and you get to keep those dollars for the business. Any questions? Duh!

  6. amy says:

    Any way you look at the problem, providers will not alter their MO unless incentives change. Today, the incentive is to do as much as possible because the more you do, the more you get paid. Sadly, the more a provider does, the more exposure they have to making mistakes. Some of these mistakes end up in malpractice law suits. If providers were more prudent about the volume of services and the volume of prescribing drugs, maybe there would be less exposure to litigation. Regardless, in today’s broken system, risk has reward. Volume pays. Incentives must change in order to benefit “all” stakeholders. Customers need to benefit from the system, not just providers. Teaching doctors about cost of care is a complete waste of time in the fee-for-service model. The real change comes when fee-for-service ends, when volume ends and when wellness and good outcomes begin to be rewarded. The Affordable Care Act begins this thinking. Republicans are busy trying to repeal the idea that they originally hatched in 1989 at the ultra-conservative Heritage Fundation. Newt Gingrich endorsed the Heritage Foundation idea back then and he wrote extensively about the virtues of mandated health care. Mitt Romney loved the Heritage Foundation idea so much that he got it enacted for Massachusetts and Romneycare is now working fine there with 2 of 3 residents supporting Mitt Romney’s inovative health care achievement. Massachusetts has an unployment rate of under 6 percent so the idea that the world will end under Obamacare is refuted by the current Massachusetts model proudly knwn as Romneycare. With Romney’s great achievement in Massachusetts, it’s a wonder why he wasn’t made Secretary of HHS. Regardless, Romneycare is a resounding success and Republicans need to begin to tell the truth about it.