Trends in US healthcare expenditures are financially unsustainable (1). I would like to propose two tweaks of the healthcare delivery process that may, in a small way, help rectify this problem.
Although there is a widespread impression that health information technology (HIT) will eventually “bend” the cost curve and put healthcare spending on a sustainable course, there is, as of yet, little data that convincingly supports this hypothesis (2).
Kaiser Permanente is a large, integrated healthcare delivery system which has invested heavily in HIT. George C. Halvorson, the chairman and CEO of Kaiser Permanente appears to have concluded that this investment will not solve the healthcare cost issue, when he was quoted in the New York Times (3/20/13) as stating “We think the future of health care is going to be rationing or re-engineering.”
Because HIT, as currently implemented, will probably not solve the healthcare cost problem, I would like to suggest a minor “re-engineering” of the electronic health record user interface which may help bend the cost curve.
At every office visit, the physician must make a myriad of decisions which incrementally effect the nation’s total healthcare expenditures. For example, the physician will have to decide which medicine to prescribe, and which radiology study or laboratory test to order.
In many situations, there is more than one acceptable choice. The physician’s ultimate decision will integrate their understanding of the disease process, the treatment’s side effect profile, their familiarity with the treatment options, patient preferences and many other variables.
I would suggest that every time a physician is about to order a test or a prescription, the cost of the test or prescription should be displayed to the physician. In the same vein, whenever a computer displays a test result, the cost of the test is immediately available to the reader. This information could then become an additional factor that the physician may choose to integrate (or ignore) at the moment when he/she is about to commit the patient and society (which is now paying >50% of all healthcare bills) to another healthcare expenditure. In terms of a risk/benefit analysis, I can see little downside to providing this cost information to physicians.
While the integration of cost information into the ordering process may help physicians minimize an individual patient’s medical expenses, it would also empower physicians to make treatment decisions that may promote the longterm viability of the healthcare system. While I acknowledge that some people will decry the notion that a physician has an ethical responsibility beyond the interests’ of their patient, I believe that physicians are morally culpable if they ignore the societal ramifications of their treatment decisions.
My second suggestion for “re-engineering” the healthcare delivery system would be more complicated to implement but is no less important.
I think physicians need to understand which treatments are truly “cost-effective” from a societal prospective. Toward this end, there needs to be a large number of medical-economic analyses which precisely define the “maximal acceptable daily treatment cost” for the major (or expensive) diseases.
Specifically, if a physician is treating a particular disease, how much medicine can the physician prescribe, in dollars per day, before the physician begins to consider the treatment as being “not cost effective.” This type of calculation, known as quality-adjusted life year or QALY has been used by the healthcare system in the past.
For example, diabetic patients will have fewer longterm complications and an increased life expectancy if their blood sugars are well controlled. However, each additional hypoglycemic (blood sugar lowering) medication will incrementally increase the short term healthcare expenditures. There are many hypoglycemic agents and the price of these medicines can range from a few cents a day to several dollars per day. While the selection of the “best” medication for the patient is very complicated (and beyond the scope of this article,) conspicuously missing from the physician’s thought process is an understanding of the cost-effectiveness (QALY) of the different treatment options.
I think it would be very useful if physicians knew what was the maximum daily expenditure for hypoglycemic medications which would be considered “cost-effective.” This information could be derived from computer simulations and based on existing Medicare claims records. Once the modeling studies have been completed, an Expert Physician Panel could review the data and issue a Consensus Statement that says “Physicians should treat their diabetic patients with the most appropriate hypoglycemic agents and attempt to maintain a total daily expenditure on hypoglycemic agents that does not exceed $XXX/day”.
Clearly, knowledge of the “maximal daily prescription expenditure” which is “cost-effective” could help physicians ensure the longterm viability of the US healthcare system and the health of the vast majority of our citizens.
Of course, if physicians don’t do this analysis ourselves, it will be imposed on society by the Federal government as a matter of fiscal necessity.
2. Kellerman A, Jones S, What It Will Take To Achieve The As-Yet-Unfulfilled Promises of Health Information Technology. Health Affairs 2013;32(1):63-68.
Hayward K. Zwerling, M.D., FACP, FACE is an a board-certified internal medicine physician who specializes in endocrinology. He practices at the Lowell Diabetes & Endocrine Center in North Chelmsford, MA. Zwerling is also the president of ComChart Medical Software, LLC.