Physicians

Cost-consciousness and clinical decision-making

With computerized health systems, physicians can place orders as easily as they can shop online at Amazon.com. Just a few clicks and your physician can purchase a panel of blood tests, futuristic imaging and diagnostic procedures that will hopefully guide their path to solving your ailments.

Search. Click. Submit. Repeat.

Except, unlike online shopping, physicians don’t see the price tags and they never get the bill. Doctors are the true consumers of health care dollars, but the rules of economics falter when the consumers aren’t the ones that pay up. This disconnect is a fundamental cause of the uncontrollable inflation of health care costs in the US. Ignorance about cost fuels spiraling inflation in healthcare because without cost-related restraint in utilization there is no incentive for suppliers of healthcare services to get any cheaper.

But the system’s stuck. While physicians ultimately control the tap of healthcare costs, exerting that control can contradict their primary objectives. Physicians feel a responsibility to do the most they can to make the patient in front of them better. If young doctors don’t order a test, a superior may berate them for not considering it in their differential. Malpractice always lingers as a consequence for a diagnosis missed. Some claim that it is irresponsible or unethical for physicians to consider cost in their clinical decision making. Perhaps good doctoring should be blind to finances. And after all, it’s no skin off the doc’s back to just click a little more, some of that money may even end up back in their own pockets.

Despite all these pressures pushing physicians to just do everything imaginable, many realize that physicians also have a responsibility to balance the health of the individual and the health of the community. No matter how much we try to ignore it, health care is a limited resource and giving more to one inevitably means less for another. In Cooke’s 2010 NEJM article on cost-consciousness in medical education she writes, “[We must] stop hiding behind the myth that every physician should and does apply every resource in unlimited degree to every patient for even minimal potential benefit”. The reality is, physicians already dictate how finite resources are allocated in the hospital. Physicians decide who gets how much of their time, who deserves a consult from a specialist and who should be in an ICU bed. Why don’t physicians exhibit the same judgment and restraint for expensive tests and imaging studies? Cost-consciousness at this scale may be beyond human cognitive capacity, especially when competing with disease differentials and medication lists. It’s far easier to count down the hours in the day and notice when all the ICU beds on one wing are full than to be mindful of the obscure strings of digits and commas that represent their health care spending. The finances of health care are far less visible but just as real.

While respect is growing for skyrocketing health care costs, the average doctor is clueless about the price tag of their day-to-day clinical shopping-sprees. In a 2008 review of 14 studies, Allan et al. found that doctors came up with estimates that were within 25% of the true cost of diagnostic tests less than one-third of the time. And, interestingly, they found that the country, level of training, and specialty of those surveyed did not impact accuracy. This tells us a few things: doctors have no idea how much they’re spending for their patients, it’s not just US doctors or super-specialists who are clueless, and most importantly, it doesn’t get better the farther along young docs get in their training. The Chief of Medicine who can diagnose Peutz–Jeghers syndrome from across the room may have no idea how much it costs to do a colonoscopy or a genetic workup for the patient. It’s not just students who are naïve and, sadly, financial insight doesn’t come with time.

For our generation, this deficit threatens to spin out of control. The stakes rise as physicians become capable of doing more and more for each and every bullet point on their differential diagnosis. Immunoassays and genetic tests are available for the obscurest pathologies. Imaging technology can produce increasingly fantastic windows into the human body. But as these options become more numerous and specialized, our grasp on what’s necessary to produce quality care only slips further.

If cost-consciousness among physicians is the goal, how do we achieve it? Competition for doctor’s time and brain-space is fierce. Cooke thinks that health finance should be integrated into medical school curriculum from the start. Educators suggest dual-degrees in business. Researchers have tried post-graduate education campaigns. Hospitals try to intervene with computerized decision-support systems. Insurance companies stall with mandatory pre-authorizations. But few interventions have shown substantial increases in awareness of cost or changes in physician behavior.

Health information technology (IT) may be partly contributing to the ease of over-zealous ordering, but it may also hold the potential to curb it. Two large randomized controlled trials conducted at a large teaching hospital attempted to show that the inclusion of costs in the ordering system itself might increase awareness of physicians and decrease the over-utilization of diagnostic laboratory tests and radiological imaging. Although it was conducted over four months and involved over 24,000 patients, the study showed a statistically insignificant 4.5% decrease in the number of laboratory tests ordered and almost identical rates in the number of imaging studies ordered. The authors concluded that more intrusive measures were needed in order to affect change, like prompts similar to those in decision-support. Price tags alone weren’t enough.

Ultimately, the judicious and cost-effective utilization of limited health care resources remains a physician’s responsibility. They’re trained to make clinical decisions and manage treatment plans but those same decisions dictate the finances of patients and the health sector as a whole. These dual roles are inseparable and increasingly consequential yet the majority of physicians are too unaware or unprepared to meaningfully incorporate financial consequences into clinical decision-making. Any efforts to reform health care policy to reduce costs and spend our health care dollars more efficiently and equitably must start with assisting doctors make better and more informed decisions for their patients. Physicians must wake up to the reality of modern medical practice and start educating themselves about the economics of their patient care methods and they must demand the information when it’s lacking. This will require a culture shift in how medicine is practiced and future generations of doctors are trained. In a world of competing priorities and information overload, physicians will need help. More cost-effectiveness data is needed so that physicians have an evidence base for rational allocation of resources. Health IT, decision-support, payment reform and institutional leadership are all essential strategies to encourage cost-consciousness and appropriate health care spending, but none can be effective in isolation. The tap of health care dollars that threatens to run dry is controlled by thousands of physicians and their daily interactions with unique patients. Only through innovative programs and education campaigns can we reduce the flow of excessive health care spending and help physicians avoid irresponsible clinical shopping sprees and begin to make evidence-based decisions with a broader context in mind.

REFERENCES
1. Cooke M. Cost consciousness in patient care — what is medical education’s responsibility? N Engl J Med 2010;362:1253-1255
2. Abbo ED, Volandes AE. Teaching residents to consider costs in medical decision making. Am J Bioeth 2006;6:33-34
3. Goold SD, and Stern DT. Ethics and professionalism: What does a resident need to learn? American Journal of Bioethics. 2006. 6(4): 9–17.
4. Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007;4(9):e283.
5. Allan GM, Lexchin J (2008) Physician Awareness of Diagnostic and Non-drug Therapeutic Costs: A Systematic Review. Int J Technol Assess Health Care 24: 158–65
6. Bates et al. Does the computerized display of charges affect inpatient ancillary test utilization? Arch Intern Med. 1997;157(21):2501-2508.

Ian Metzler is a medical student at Harvard Medical School, currently studying health systems improvement at Children’s Hospital Boston.

Costs of Care (Twitter: @CostsOfCare), where this post was originally published, is a Boston-based nonprofit organization that collects anecdotes from doctors and patients. We feel these stories are poignant because they put a face on some of the known shortcomings of our system, and also because they unveil how commonplace and pervasive these types of stories happen.

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amorous snakeJake LongKandiHilfe bei DepressionenIan Metzler Recent comment authors
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amorous snake
Guest

Hey very nice web site!! Man .. Excellent .. Superb ..

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Jake Long
Guest

I agree, I think that those types of classes should be infused into the curriculum. Doctors should have the knowledge that they need to make the best decisions possible. Of course, I think it’s important to lean in favor of giving the best treatment to the patient.

Kandi
Guest
Kandi

Hello – I am currently recruiting for a Medical Director on a Recovery Audit Contractor assignment and need a few clinical questions to ask candidates in an interview. Specifically, to assess them on their ability to make fair, rational, and reasonable clinical assessments. This position will aid us in looking at standards of care and determining when excess utilization may have occurred. I found this article VERY enlightening!

Any help would be great!

Hilfe bei Depressionen
Guest

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Dr. Mike
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Dr. Mike

@ Ian, You are confusing issues here. My whole point is that health care services and resources are not what is limited, money is. For someone to ask me, the physician, to determine who should or should not have access to a given resource based on their ability to pay would be ridiculous. But it is equally ridiculous for me to categorically deny access just on the principle that it costs too much period. So what you really must be talking about is my adherance or non-adherance to practice guidelines, and that is a whole different discussion. You cannot ask… Read more »

MD as HELL
Guest
MD as HELL

(Hint, you can do this and still have insurance/medicare/medicaid)

Not so far.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Truth again. I forgot the computer scientist hat. CPOE and EMR is slow, clunky and inefficient. It takes longer to see each patient, and each patient gets less time with me. So, it’s a lose-lose scenario.

MD as HELL
Guest
MD as HELL

That is correct.

MD as HELL
Guest
MD as HELL

“I think physicians should expect an insatiable desire for cure from patients.”

What makes you think all your patients are going to be sick? It is the worried well and the worried chronic but stable patient that spends like a drunken Congressman.

You don’t sound like you are heading for primary care.

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Truth.

rbaer
Guest
rbaer

Ian,
I have to agree with Quack and hell MD, although you are certainly right for the truly sick (or: reasonably worried) patients.

The other thing I wanted to mention: COE (computer order entry) makes ordering more cumbersome and time intensive, not less. In the past, you just had a form, made a checkmark (or told the MA exam and question and she took the signature stamp) and that was it. Not that I think it should be supereasy, just commenting on the preparation of your first thought.

Ian Metzler
Guest

Thank you to everyone for the thoughtful discussion. I write from the soon-to-be physician perspective, but I firmly believe that the burden of cost-consciousness should also be shared by patients, providers, insurers and policy makers. This must be a team effort if any progress will be made. But to the many commentators, MDs among them, that shirk the responsibility of cost-awareness onto the “demanding” patient, I ask you to consider the psychological state that a patient is in. How could you possibly expect anyone, when faced with a threat to their life in the form of illness, to rationally consider… Read more »

Craig "Quack" Vickstrom, M.D.
Guest
Craig "Quack" Vickstrom, M.D.

Mr. Metzler, At one time, the physician and the priest were one and the same person. But time and knowledge have expanded such that we are now two different people. One looks after the body, the other after the soul. I do not pretend to be a priest. The basic duty of the physician is to diagnose and treat disease and repair injury in his/her patient. That alone is enough responsibility for any one wo/man’s plate. It’s nice when we can prevent disease and injury as well, but we really cannot imprison or control our patients. Our society, unfortunately, has… Read more »

rbaer
Guest
rbaer

Margalit,

That taxpayers vote on this (what? on every device, every new drug, every new procedure) is like taxpayers deciding, say, to what extent bridges or nuclear power plants should be constructed to resist natural disasters, or how flight control centers should be staffed, or what weapon systems the airforce should purchase … it’s a question that requires maximum expertise and is, IMHO, not open to direct democracy.

Margalit Gur-Arie
Guest

The recommendations for a national health basket of service should require expertise, but ultimately people will have to decide how much they want to be taxed. I am not suggesting a vote on every pill, but in the fantasy world of national health care, I presume the hard choices will be made on election day by those who pay the bills. We don’t vote on what weapons the air force chooses, but we do vote on platforms (and candidates) to increase or decrease defense budgets, and in local elections we do vote on specific Propositions to increase taxes for specific… Read more »

MD as HELL
Guest
MD as HELL

The 2010 midterm clearly said taxed enough already. It clearly said stop the bleeding. It clearly expressed buyer’s remorse. It clearly was a turn away from bigger government.

Most voters are not paying the bills. That is the other problem.

Margalit Gur-Arie
Guest

“how many patients (with a life theratening condition, I assume)would choose the slightly less effective (but cheaper therapy) based in the situation that both are covered by a 3rd party?” Yes, this is the problem. However, I don’t believe that what we perceive to be the solution at this particular moment in time, should be directed or unduly influenced by physicians. In my opinion your job is to recommend the best possible course of action from a clinical perspective. This includes abstaining from frivolous orders, whatever the rationale for those may be. The rest is up to the patient. I… Read more »

rbaer
Guest
rbaer

“Otherwise, whatever trust remains between patients and doctors will disappear into thin air (as it did during the HMO gate-keeping glory days). For example, I would expect a physician to say something like “this therapy is extremely expensive, it has 15% chance to help you, while this other therapy is a fraction of the price and has 10% chance of helping”. At this point the good citizenship should be left to the patient.” Margalit, how many patients (with a life theratening condition, I assume)would choose the slightly less effective (but cheaper therapy) based in the situation that both are covered… Read more »

pcp
Guest
pcp

I realize the “drones” reference is humorous, but are you really asking docs to say to their patients something along the lines of “Yes, there is a small chance that this treatment may benefit you, but we’re going to forego it, because, in my opinion, any other way in which society uses the money is more appropriate”!

rbaer
Guest
rbaer

It’s a principal decision that beneficial things are covered and nonbeneficial or unproven stuff is not, not and individual assessment.

Society already does weigh on risk of human life vs other benefits; take car traffic, for instance: there are standards, but you are still allowed to drive your 60 collectible car w/o air bags, crumple zones, ABS, and not everyone maintains their cars. Requiring 4 airbags, ABS, good crumple zones and biannual safety checks would save lifes, but immobilize a lot of poor people and cost a lot of resources, resources that society thinks are not worth the outcome.

Margalit Gur-Arie
Guest

“beneficial” is not an exact term, so the principal decision will vary with individual assessment.

I do agree that a decision needs to be made, but do you think the physician should be the one making that decision (2 cans of Napalm or 5% better odds for Mr. Jones)?

Margalit Gur-Arie
Guest

Dr. Shah, I agree with do no harm and I agree with effectiveness assessment. Cost effectiveness, I’m afraid is something that a physician should perhaps share with the patient, but as Dr. Subramanian puts it simply, this is not a decision that belongs with the doctor. Patients need to know that their physician’s sole concern at the point of care, and elsewhere, is the one patient, and the ethical responsibility to the individual patient must trump the ethical responsibility of a good citizen to society as a whole (within the limits of the law). Otherwise, whatever trust remains between patients… Read more »

Dial Doctors
Guest

I agree with both Dr. Shah and Ms. Gur-Arie. Do no harm must be a doctor’s first and most important responsibility. Cost effectiveness may be discussed with a superior and the patient. Including the patient while allow doctors to advocate for their patients.

While we do no harm, patients are entitled to help make a decision which affects their lives. Even if a therapy is only 5% more effective and incredibly expensive then it’s up to the patient to help decide.

Neel Shah, MD
Guest

@Margalit, who said anything about recource allocation being a doctor’s primary responsibility?

The first responsibility is to do no harm. If a test or treatment is known to be safe, the second responsibility is to make sure it has a reasonable chance of working. If it is safe and effective, the final responsibility is to make sure it is reasonably cost-effective.

Once we accept this, we can move on to the more important and challenging question of what “reasonably cost-effective” means and how a doctor at the bedside should go about determining this.

April
Guest
April

Trying to compare costs is extremely frustrating. Right now, I need to have a mammogram performed, and I have been calling around to find out how much it will cost me. When I tell the health provider that I have high deductible insurance, but the mammogram will not be covered by my insurance because I have not met the annual deductible, they say that they are unable to tell me how much the procedure will cost. They say I must come in and get the procedure first and then they will send the bill to my insurance company to determine… Read more »

Siva Subramanian
Guest

Valid point.

However, this is you (the patient) making a cost-concious decision, which you should be empowered to make.

I think the author is suggesting that the doctor make this cost-based decision for you….

pcp
Guest
pcp

Both the provider and the insurer are lying. They both know, based on what your coverage is, how much the mammogram will cost.

However, your contract is with the insurer, not the provider. You should demand to know how much you will pay at the various facilities. If they stonewall you, go to the next level, and be sure to get your HR rep involved.

Ian Metzler
Guest

@April – Thanks for sharing your struggle, I really admire your efforts. So many other people are oblivious to the realities your facing and are later blindsided by the bill. I wish there were more resources for you or a clearer path and I hope that the next generation of physicians will be better able to answer your questions.

April
Guest
April

I’ve decided that the only reasonable way to proceed is to go ahead and make the appointment for my mammogram. When I arrive at the facility, I will tell them how much I am willing to pay for the procedure. They can then either accept my offer, reject my offer, or make me a counteroffer. If they are annoyed that I took up a time slot, then they should learn to state their charges in advance like other businesses do.

Siva Subramanian
Guest

As a patient, I find it very concerning to know that a doctor will take into account the price of a treatment before prescribing it to me (or my loved ones).

IMHO, there should be only TWO things that are used by the doctor to determine what treatment is chosen or what options are presented to the patient – patient safety and quality of the outcome. (Did I miss anything else?)

Am I too liberal to think thus?

-Siva