At the Society of Hospital Medicine’s annual meeting last week in Dallas, Lenny Feldman of Johns Hopkins presented the results of a neat little study. His hypothesis: physicians given information about the costs of their laboratory tests would order fewer of them.
Feldman randomized 62 tests either to be displayed per usual on the computerized order entry screen or to have the cost of the test appear next to the test’s name. Some of these were relatively inexpensive and frequently performed tests. After randomization, for example, the costs of hemoglobins ($3.46) and comprehensive metabolic panels ($15.44) were displayed, while TSHs ($24.53) and blood gases ($28.25) were not. He also randomized more expensive tests: the costs of BNPs ($49.56) were displayed, while hepatitis C genotypes ($238.62) were not.
The educational intervention was surprisingly powerful. Over the six-month study, the aggregate expenditures for each test whose costs were displayed went down by $15,692, while non-displayed tests had a mean increase of $1,718. Over the entire group of 31 tests whose costs were shown to physicians, costs fell by nearly $500,000.
Coincidentally, last week’s Archives of Surgery reported the results of an intervention aimed at decreasing lab ordering on the surgical services of Rhode Island Hospital. There, simply announcing the service’s overall expenditures on non-ICU laboratory tests for the prior week at a house staff conference led to significant savings: $55,000 over an 11-week study period.
Have we found the Holy Grail, the key to flattening the cost curve? A little physician education leads to increased awareness of the cost consequences of their choices and, voila, our economy is rescued from the brink of disaster. How nice.
Before we get too ecstatic, it’s worth reflecting on the long, sobering history of cost reduction efforts in healthcare. Luckily, Steve Schroeder, now a distinguished professor of medicine and health policy at UCSF, recently did just that in the Archives of Internal Medicine. But before I get to Schroeder’s reflections on our cost containment journey, I must digress with a personal story, since his counsel was central to my career choice.
In 1985, when I was a second year UCSF medicine resident, I made an appointment to meet with Schroeder for career advice. At that time, Steve was chief of our Division of General Internal Medicine and a national leader in academic medicine and health policy. I had an idea that I wanted a career in academic general medicine, but my interests were broad and vague. I sat in his office, intimidated. He asked me about my plans. “Well, I love general medicine, seeing patients and teaching, and I’m interested in policy, healthcare economics, epidemiology, rationing, and ethics.”
Steve took a deep breath. “That’s a disaster,” he said, his tone sympathetic but unambiguous. “To succeed in academic medicine requires focus. You’ll be competing against people who do only one thing. You can’t be a dilettante.”
I grew depressed. I knew that I was wired to be a generalist; I could no more focus exclusively on ethics or epidemiology than I could be a dermatologist or accountant. My career plans torn asunder, I thanked him for his advice and began to slink out of the office. As I reached the door, wondering whether to take the GMAT, something possessed me to stop and pose a final question to him.
“Steve, what did you focus on?”
“Oh, I completely ignored that advice,” he said with a mischievous smile, as he turned and pointed to his bookshelf, which had a clinical textbook he edited, along with books – some he had written – on health policy, ethics, epidemiology, and ethics.
“Why did you give me that advice, then?” I asked, more flabbergasted than annoyed.
“Because it is the right advice for most people,” he said. “But some people, probably like you and me, need to stay broad. I just want you to understand the risks and to be prepared. As a generalist, you’ll need to move from issue to issue, reinventing yourself every few years, and you’ll constantly need to bring together teams of experts to help you accomplish your goals.”
And that’s what I did. Some days, my eyes wander to my own office bookshelf, and I realize that it looks almost exactly like Steve Schroeder’s did that day in 1985. And I smile.
Now that I’ve established Schroeder’s bona fides as a truly wise person, let’s return to his recent article on the history of healthcare cost reduction efforts. Steve has walked this particular walk in his career, beginning as founding director of the George Washington University HMO, extending to his time as our DGIM chief, and peaking during his 12 years as president of the Robert Wood Johnson Foundation. Steve begins the article by noting that cost reduction gathered steam during the 1970s, when we were, as a nation, spending – OMG – 7.5 percent of our GDP on healthcare. While 7.5 percent seemed large, the burning platform came from projections that these costs might grow to an “unsustainable” 10 percent. (In case you’re missing the irony, healthcare now accounts for 17 percent of the GDP, projected to rise to 30 percent by 2032).
In the article, Schroeder reviewed several cost reduction strategies that have been tried over the past 40 years, ranging from reducing the “pro-technology bias” of our payment system, to training more generalists and fewer specialists, to giving physicians information about the costs of care. That’s right: in JAMA in 1984, Schroeder and colleagues reported the results of an educational intervention designed to sensitize residents to the costs of their care. Combining lectures on costs with chart audit and feedback, they found a slight reduction in the use of a few selected laboratory tests like the PTT, but no overall impact on costs. The effort was a bust.
After reviewing this history, Schroeder’s conclusion is that cost reduction efforts either didn’t work, or worked for a short while and then petered out, or led to compensatory increase in costs (the proverbial “squeezing balloons”). For example, while Medicare’s prospective payment system clearly resulted in shorter hospitalizations, the compensatory increases in high-intensity outpatient care (such as in ambulatory surgery) chewed up most of the savings. Other changes, such as changing the pro-technology payment bias or training more generalists, were countered by powerful political forces, a trend that continues today.
Schroeder’s bottom-line message is sobering. While he applauds the fact that we are now trying several new strategies (curbing fraud and abuse, using electronic health records, paying for performance) layered on top of the traditional ones, he writes, “it seems naïve to assume that these latest efforts will be any more successful than their predecessors.” He continues,
In the long run, reining in costs will require mobilizing political forces that can withstand the inevitable claims of rationing sure to come from the industries currently benefiting from the 17% of the economy spent on healthcare, and from consumers who have come to expect unlimited access to what they feel they need.
Do the two new studies – ones in which educational interventions appeared to work – mark a new era, one in which an overall increase in cost consciousness among physicians, coupled with a new ability to provide real-time data via computerized order entry, will lead to meaningful, durable cost reductions? I’m not too hopeful. I’d bet that once the novelty of interventions such the ones used by Feldman and the Rhode Island surgeons have worn off, the cost data will become white noise and folks will revert back to their comfortable, profligate ways.
So what will work? To make a meaningful and lasting dent in healthcare expenditures, I believe we’ll need to change some or all of the following:
- Just like certain medications are “non-formulary” and thus far harder to order, certain laboratory tests and radiologic studies will need to be taken “off formulary” – perhaps requiring subspecialty blessing or acknowledgment that the ordering physician has read through a brief summary of the test’s accuracy, its costs, and the alternatives before being allowed to click “Order.” How to accomplish this without gumming up work flow and driving ordering physicians batty needs to be on the agenda of some very smart operations engineers and IT gurus.
- Physicians will be more careful about test ordering if the costs of the tests are partly coming out of their own hides. The trick here is to enact strategies that don’t provide too strong an incentive for underutilization and that have robust quality and safety protections. The hope is that Accountable Care Organizations and bundled payments will be just the ticket, though the response to Medicare’s initial ACO proposal did not exactly resemble the front entrance of WalMart on Black Friday. Hopefully, with some tweaks, doctors and hospitals will be willing to stick their toes in this integrated care/shared incentive pool.
- We somehow need to change the culture of medicine, and of training. This’ll be the hardest nut of all to crack, but there is hope. For a brief glimpse into how much the culture has already changed, one merely needs to look back at Schroeder’s 1984 JAMA article. In it, he notes that his research team chose to focus their interventions on the interns and sub-interns, not the attendings. Why not? “…As with many other university hospitals,” he writes, “most attending physicians had expressed little interest in modifying the costs of medical care.”That was 1984, when virtually all the attendings were subspecialists coming out of their research labs or procedural suites to attend on the wards for one month each year. While we haven’t exactly solved the cost problem, I can’t imagine someone saying the same thing about our ward attendings today, certainly not the hospitalists I work with.That’s progress.
As I noted recently, it is critical that physicians focus on cost and waste reduction with as much passion and skill as some have, thankfully, been applying of late to quality improvement. Our systems need to be structured to promote this work, and our culture must encourage thoughtful and ethical cost containment as a core value. It’s not hyperbolic to say that the future of not just healthcare but our overall economy hangs in the balance.
As we embark on this crucial journey, while studies like Feldman’s give us hope, Schroeder’s historical perspective should gird us for the hard work ahead.