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High‐Value Healthcare

Christopher Moriates, MDUCSF Division of Hospital Medicine

Advances in Internal Medicine KeynoteMay 20 and June 24, 2013

CMoriates@medicine.ucsf.eduTwitter: @ChrisMoriates

Disclosures

• I do not have any financial relationships or commercial interests to disclose

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As an intern, I rotated through the Emergency Department…

"To improve emergency room throughput we've replaced the front door with a CT scanner."

Cartoon from ACP Internist Weekly Caption Contest 7/3/2012. Caption by Brett Montgomery, MD, from Richmond, Va

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Why Do We Do This?

Are We Treating The Patient In Front of Us?

Are We Connecting the Evidence to the Care We Provide?

Cartoon by T. McCrackenwww.mchumor.com

How much does this cost?

Illustration by Peter ArkleBloomberg.com 7/11/11

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Cost of Headache evaluation

• CT Head– Minimum : $750 ‐ (Altus, OK)

– Average :  $1,150

– Maximum:  $4,200 ‐ (Ketchikan, AK)

– UCSF:  $1,800 ‐ 2,475

– SFGH:   $1,800

SOURCE: Newchoicehealth.com (accessed 12/29/11)

Today’s Agenda

• Why Physicians (Should) Care About Healthcare Costs

• How Are We Teaching Physicians?– The UCSF Cost Awareness curriculum

– An example case presentation

• How Do You Operationalize These Ideals At The Bedside?– Highlight one example High‐Value Care Project

• Conclusions

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Why show physicians the costs?

• It is part of physicians’ professional responsibility to use healthcare resources judiciously

• Physicians need to be trained about healthcare costs

• Astounding amount of healthcare waste and “unnecessary testing”

• Price transparency movement

• Value-Based purchasing

• It is important to the patient in front of us

Slide showing % of GDP goes here?

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It Is About The Patient In Front of Us!Side‐Effects May Include: Financial Ruin

• Medical bills are the leading causefor personal bankruptcy in the United States

• Middle‐aged, college‐educated, homeowners

• >75% were insured!

Himmelstein DU, Warren E, Thorne D, Woolhandler S. MarketWatch: Illness And Injury As Contributors To Bankruptcy. Health Affairs, no.W5(63), 2005. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009;122(8):741–6. 

An Uninsured Patient’s Perspective

Clip courtesy of This American Life from WBEZ Chicago

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…Then The Bill Comes

It is About the Patient In Front of Us:Putting Off Care Because of Cost

Percent who say they or another family member living in their household have done each of the following because of the cost:

Not filled a prescription for a medicine

Cut pills in half or skipped doses of medicine

Skipped dental care or checkups

Put off or postponed getting health care needed

Had problems getting mental health care

Relied on home remedies or over-the-counter drugs instead of going to see a doctor

Skipped a recommended medical test or treatment

Source: Kaiser Family Foundation Health Tracking Poll (conducted May 8-14, 2012).

‘Yes’ to any of the above 58%

8%

16%

25%

24%

29%

35%

38%

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Chart design: Luke ShumanSources: Archives of Internal Medicine, US Centers for Disease Control and Prevention

Exploding Health Care CostsSince 1987, US health care spending per capita has more than doubled, and the cost borne by patients continues to rise. 

Andy Grove, Wired, 2012

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Two separate motivations to consider costs:

1. Macroeconomic resource stewardship

2. Financial safety of the patient in front of us

The Sweet Spot: Where these two motivations align

Good for 

Society

Good for 

Individuals

For example: Generic Drugs 

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Generic Drugs

• Approximately 4 of 10 physicians report they “sometimes or often” prescribe brand‐name drugs when a generic is available – Certain physician‐industry relationships were significantly associated with prescribing brand‐name drugs

• Physician perceptions– Nearly 50% of physicians hold negative perceptions about the quality of generics

– 75% report that pharmaceutical representatives are their most common source of drug information

References: Cambell EG, Pham-Kanter G, Vogeli C, Iezzoni LI. JAMA Internal Medicine 2013; 173(3):237-239Shrank WH, Liberman JN, Fischer MA, et all. Ann Pharmacother. 2011;45(1):31-38

The Case of Statins

• 8 statins currently on the market: 5 are available as generics

• In 2011, fewer prescriptions for generic Simvastatin written than for Lipitor (Pfizer)

• U.S. Primary Care physicians’ use of branded statins results in $5.8 Billion excess annual spending

Simvastatin

References: Green JB, Ross JS, Jackevicius CA, et al. JAMA Int Med 2013, 173(3):229-232

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Sources of $750B of Waste and Excess in Healthcare

IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.

Previously widely ignored in medical training:

“The reasons for this silence are historical, philosophical, structural, and cultural.

...Combating such forces is a tall order, but I believe that medical educators have an

obligation to address cost.” - Dr Molly Cooke (2010)

Reference: Cooke M. Cost consciousness in patient care‐‐what is medical education's responsibility? N Engl J Med 2010;362:1253‐5 :

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The ACGME also says so…

• Under the Systems‐Based Practice core competency requirement:

• The Milestones Project will present many Cost‐Related Milestones

“Residents are expected to… incorporate considerations of cost awareness and risk‐benefit analysis in patient and/or population‐based care as 

appropriate.” - ACGME

Reference: ACGME: Common Program Requirements. 2007. (Accessed 10/25/2010)

Introduction to the UCSF Cost Awareness Curriculum

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Global Objectives

• To increase medicine residents’ awareness of value, quality, and cost in medicine

Increase Awareness

Improve Attitudes

Change Behavior

• Cultivate more cost‐effective physician ordering behaviors

• To improve physician attitudes regarding sustainable spending

Introduction

“Core” topic and case assigned

Interns divide into two groups

Guideline Review

•Review literature • Find evidence based best‐practice guidelines

• Suggest cost effective workups

Case Analysis

•Review recent case from our institution•Analyze hospital bill, and clinical chart to evaluate care provided

•Reflect on our own clinical behaviors

Case review debrief

Case based noon conference for ALL residents

Process:  

How the curriculum is delivered

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Case‐Based Noon conference shared with students, residents, and attendings.

Includes concrete “Action Items”: 2 things to “Start” and 2 things to “Stop” doing based on the conference

Health Care System

IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.

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Providing “Value” in Health Care

Quality

CostVALUE =

UCSFCost Awareness Curriculum: Evaluation

• Highly relevant to their clinical practices (mean, 4.6 +/‐ 0.6 on a 5‐point Likert scale; median, 5)

• Likely to change their ordering behaviors (mean, 4.3 +/‐ 0.7; median, 4) 

• Pilot: 176 evaluations from 10 conferences

Moriates, et al. JAMA Int Med, 2013

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http://www.nejm.org/doi/full/10.1056/NEJMp1205634

Through modules detailing common admission diagnoses, he emphasizes the principles of evidence-based medicine and provides information about associated costs…

Two residents’ experience with the curriculum:

…the purpose of this curriculum is not to teach rationing health care; it’s to teach rational health care. By learning the fundamentals of evidence-based medicine, but keeping the best interests of the patient in mind, we’ve learned how to use the most current guidelines to provide individualized yet cost-effective care.

http://primarycareprogress.org/blogs/16/191

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Example: (Abbreviated) Case Presentation from UCSF Cost 

Awareness Curriculum

A Patient Was Admitted to the Medicine Service Last Winter…

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Patient presentation: Ms. J.

• 65 year‐old woman with a recent diagnosis of COPD 

• Started on albuterol inhaler 1 month ago by primary doctor

• She has “attempted to use the inhaler” but has noted increased wheezing and productive cough

• In the Emergency Department: Started on continuous nebulized bronchodilator therapy, given Solumedrol 125mg, doxycycline, Chest X‐ray and CT Chest

Patient Presentation (Continued)

Physical Exam:

T: 36.3 HR: 90 BP: 160s/80s RR: 18 O2sat: 96%RA

GEN: sitting in bed, nebulizer on, speaking in short sentences, short of breath

CV: distant heart sounds, RRR, nl S1,S2, no m/g/r

CHEST: accessory muscle use, diffuse expiratory wheezing throughout the lung fields but good air movement throughout both lungs, increased expiratory phase

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Initial Work‐up

What are your standard orders for a patient with COPD exacerbation?

How much does this cost?

Illustration by Peter ArkleBloomberg.com 7/11/11

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Some facts about COPD

• COPD affects more than 6% of adults in the United States, accounts for $32 billion in direct health care costs, and is the fourth leading cause of death

• In 2006, there were approximately 600,000 hospital admissions for acute exacerbation COPD, making this 1 of the 10 leading causes of hospitalization nationwide

Lindenauer PK, et al. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease. JAMA. 2010;303(23):2359‐2367.

Imaging

• CXR = $251

• Non‐Con CT Chest: $2,755

• Contrast 350mg = $341

Price = Estimated hospital charge

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Nebs vs MDIs

The Evidence: Nebs vs MDIs

• Systematic reviews: No significant differencebetween devices in any efficacy outcome in any patient group

• Studies: Bronchodilator delivery by an MDI isequivalent in acute treatment of adults with airflow obstruction. 

Dolovich MB, Ahrens RC, Hess DR, et al Chest. Jan 2005;127(1):335-371.Turner MO, Patel A, Ginsburg S, FitzGerald JM. Archives of internal medicine. Aug 11-25 1997;157(15):1736-1744

Mandelberg A, Chen E, Noviski N, Priel IE. Chest. Dec 1997;112(6):1501‐1505. 

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Patients Misuse Their Inhalers!

Recent study: 

• 86% of patients misused their 

inhalers

(some did not even take the cap off!)

• All of them (100%) were able to achieve masteryafter training!

Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. Journal of general internal medicine. Jun 2011;26(6):635‐642. 

So, what happened to our patient?

• Around‐the‐clock nebulized bronchodilator therapy (“Nebs”) every 4 hours x 3 days

• Transitioned to Metered‐Dose Inhalers (MDIs) prior to discharge on her last hospital day ‐ Never received dedicated inpatient MDI teaching!

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Patient Presentation ‐ Update

Anybody want to guess what the final hospital bills charged was (not including physician fees)? 

Ms J. ‐ Total estimated hospital bill

Summary of current chargesRoom at $7,277 x4 days $29,108Pharmacy $3,969   Lab $4,394Supply/Devices $2,272Radiology $250CT Scan $2,755Respiratory Services $4,605Emergency Room $2,277EKG $380

Total of Current Charge       

$50,103

NOTE:Physician fees billed separately

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Ms J – Respiratory Care Charges

• Continuous Nebs per hour = $104

• Small Volume Nebs Treatment = $258 each

How Do You Operationalize These Ideals At The Bedside?

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The Cost

•During Fiscal Year 2012, the medicine servicealone spent more than $1MILLION on 25,114 nebulizer treatments for 1200 NON‐ICU patients

•UCSF Spent >$3.5MILLION hospital‐wide

Nebs No More After 24!Help us improve transitions from nebulizers to metered dose inhalers

(MDIs) and provide patient education about proper MDI use

What Can You Do?

Use MDIs at admission UNLESS there is an indication for nebulizer therapy

Transition your patients from nebs to MDIs after 24 hours, if appropriate, AND write an order for RT to provide MDI teaching

Improving Use of Appropriate Respiratory Therapies A Collaborative Initiative Between Respiratory Therapists, Nurses, and Physicians In Partnership with the Division of Hospital Medicine High-Value Care Committee

MDIs are as effective as nebulizer treatments!

MDIs provide high value, high quality patient care!

We can teach and train our patients on correct MDI use while in the hospital! Talmadge E. King, Jr., MD

Pulmonologist and Chair of UCSF Department of Medicine“Open mouth technique: Hold MDI two finger widths away from your lips.“

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1017

680

449505 496

0

200

400

600

800

1000

1200

Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12

Nebulizer Usage ‐ 14M

UCSF Division of Hospital Medicine High Value Care Committee

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Current Philosophy

• Focus now on the “low‐hanging fruit”:  interventions with low or no benefit

• Goal:  Reduce inappropriate care that does not help (or even harms) patients

• Ultimate outcomes:  better patient care, reduced cost

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High‐Value Care Projects

• DeSTRESS your patients:Decrease inappropriate stress ulcer prophylaxis

• iReduce iCal: Order ionized calcium only when needed

• IV‐to‐PO Medication Transitions

• Step‐down/telemetry utilization project

Our Future Together

• THE BEST CARE AT THE LOWEST COSTS for our patients

• Help disseminate education 

nationally

• Contribute to the national 

movement for better healthcare value

• Popularize stories about the harms of overtreatment and 

healthcare costs

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Less Is More “Teachable Moments”:Trainee Perspectives –

(Accepting articles now!)Brief articles that present patients' and physicians' perspectives on their health care experiences, with special emphasis on examples when more care is not always better, even to the point where it is perceived as harmful. 

Maximum specifications: 500‐800 words, 2 authors.

Acknowledgements:

Dr. Michelle Mourad

Drs. Neel Shah and Vineet Arora

Dr. Bob Wachter

Drs. Andy Lai, Krishan Soni and Sumant Ranji

The High‐Value Care Committee

Dr. Stephanie Rennke

Maria Novelero

Katie Quinn

UCSF Internal Medicine Residency Program

Drs. Harry Hollander and Brad Sharpe

Drs. Kara Bischoff and Seth Cohen

UCSF Center for Healthcare Value

Lisa Schoonerman

Drs. Clay Johnston and Deb Grady

Dr. Rita Redberg

American College of Physicians

Dr. Molly Cooke

Dr. Daisy Smith

Health Professional Education Pathway

ABIM Foundation

Dr. Talmadge King

Our Patients

Questions / CommentsTHANK YOU!

CMoriates@medicine.ucsf.eduTwitter: @ChrisMoriates