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The Medical Professionalism Blog

Where, Oh Where Do Physicians Learn About Cost-Effectiveness?

The Institute of Healthcare Improvement (IHI) defines the Triple Aim as:

  • Better health (population health)
  • Better care (quality improvement)
  • Reduced cost

Although many quality improvement organizations and delivery systems are focused on the Triple Aim, cost is not often a part of their efforts.

Similarly, there are few curricula for medical students and residents on appropriate use and cost reduction. IHI’s own Open School, targeted to trainees and faculty sponsored by IHI, has an excellent curriculum on patient safety and quality but little or no material on costs.

It seems that there is a void in learning experiences for residents regarding this issue despite calls for reforms to address this competence and an ACGME requirement for residency programs “to incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based as appropriate.” Thomas Nasca  et al. rightly acknowledged the need for “sensitivity to cost-effectiveness” in their recent New England Journal of Medicine article. In the article, the authors called for the Next Accreditation System (NAS) to “enhance the competence of future physicians in areas of relevant to well-performing, efficient and cost-effective health care system…”

There are probably a handful of residency programs and specialty societies like the American College of Physicians who are currently developing a formal curriculum to address this knowledge gap in their residents and members, respectively.

I recently visited the University of California, San Francisco to learn about its residency curriculum. With the support and guidance of Dr. Bob Wachter (an expert and leader in patient safety and the hospitalist movement, fellow blogger and ABIM chair-elect), residents Drs. Chris Moriates and Krishan Soni created case-based conferences to develop a cost-awareness competency to add to their quality improvement and patient safety curriculum.

The four steps cited by Dr. Moriates (based on current work with ACP’s High Value, Cost-Conscious Care curriculum committee) to develop this competency are:

Chris Moriates, MD

Chris Moriates, MD

1) Know the benefits, harms and costs of the interventions that you offer patients

2) Decrease or eliminate care that provides no benefit and/or may be harmful

3) Choose interventions and care settings that are more efficacious and less expensive when available

4) Rely on formal cost effectiveness analysis for those interventions that are both more efficacious and more expensive to determine relative value

The essence of the case conferences is not to discuss how to cut costs but first and foremost to focus on evidence-based clinical guidelines. Generally, going outside the normal standard of care proves not to be cost-effective even when the guidelines do not explicitly take cost into consideration, according to Dr. Moriates.

A recent cost conference was to examine the work up of a post-surgical 59-year-old woman with a potential pulmonary embolism (PE). Knowing the degree of probability of having a PE dictated less or more aggressive diagnostic tests. Without knowing that algorithm – which is contained in the guideline – often leads to more aggressive and costly diagnostic tests.

Like others I have written about in recent weeks in this blog, Neel Shah from Costs of Care and Andrew Morris-Singer from Primary Care Progress, Chris Moriates has his story of an emergency room CT scan ordered for a headache as a result of a residency insisting on 100% certainty. This experience and a supportive faculty propelled him to find a passion for this type of teaching and learning.

But this type of curriculum is a rare indeed. If you have a learning program about cost awareness, please write me. The ABIM Foundation is trying to identifying such learning curricula to signal to other residency programs the importance and possibilities of developing such approaches.

Academic medical centers appear to be best suited to develop thoughtful learning experiences on costs with their focus on the science of medicine and professional orientation on the patient and the larger needs of society. This cost-consciousness competency can no longer be neglected.


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