Balancing the Value Equation: Teaching and Assessing Cost Effective Care

1. Balancing the Value Equation:Teaching and Assessing Cost Effective Care

2. Workshop Goals • Prepare faculty involved in resident education to more effectively practice and teach principles of high-value cost-conscious care (HVCCC) and assess residents’ ability to provide HVCCC • Develop ongoing collaboration between regional institutions in the area of HVCCC

3. Workshop Objectives • Define HVCCC and appreciate its importance • Identify and understand basic principles of HVCCC • Recognize resources available to learn about and teach HVCCC • Apply principles of HVCCC to your patient care • More effectively teach principles of HVCCC • Assess residents’ competency in providing HVCCC using an assessment tool based on milestones • Share ideas with colleagues regarding teaching and evaluation of HVCCC • Describe potential methods of measuring the impact of an assessment tool

4. Introduction Outline • The value equation • Why should we care? • Review ACP’s High Value Care curriculum • Review Choosing Wisely campaign • Review barriers to high value care

5. The Value Equation Benefit Value = Cost

6. High cost Low cost No improved outcome Improved outcome Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum

7. High cost Low cost • MRI for non-specific LBP • Coronary angiography in pts with stable chronic angina • Sinus CT • CT/MRI for simple syncope with normal neuroeval • Daily labs • Annual pap smears • Preoperative CXR in asx patients • CHF peptide (BNP) No improved outcome • Anti-retroviral therapy for HIV • ICD placement when meets criteria • Vaccinations • Pap smear • ASA in CAD • Diabetes education • Good history & physical Improved outcome Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum

8. Ann Intern Med, 2012

9. Why should we care? • Health system need • Public & physician perceptions skewed • ACGME Next Accreditation System • Residents currently get little or no training • Within the current healthcare system, no real disincentive to curb providers’ ordering practices

10. Health System Need Healthcare costs in the United States are increasing at an unsustainable rate: • $253 billion in 1980 • $714 billion in 1990 • $2.6 trillion in 2010 Boston: Health Reform Program, Boston University School of Public Health; 2005

11. Approximately 30% of Healthcare Costs are Wasted Care • $250-325 billion/year in “unwarranted use” • $75-100 billion/year in “provider inefficiency and errors” • $25-50 billion/year in “lack of care coordination” Thomas Reuters, October, 2009

12. We are ordering more tests… tests imaging Uwe E. Reinhardt blog, NY Times, 12/24/2010.

13. Physicians are responsible for 87% of wasteful spending Boston: Health Reform Program, Boston University School of Public Health; 2005

14. Why should we care? • Health system need • Public & physician perceptions skewed • ACGME Next Accreditation System • Residents currently get little or no training • Within the current healthcare system, no real disincentive to curb providers’ ordering practices

15. Public Perception

16. Views of US Physicians About Controlling Health Care Costs, JAMA 2013 • 2556 physicians responded to the survey • Who has a “major responsibility” for reducing health care costs? • trial lawyers (60%) • insurance companies (59%) • hospitals and health systems (56%) • pharmaceutical and device manufacturers (56%) • patients (52%) • practicing physicians (36%) • CONCLUSION: “US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.”

17. Why should we care? • Health system need • Public & physician perceptions skewed • ACGME Next Accreditation System • Residents currently get little or no training • Within the current healthcare system, no real disincentive to curb providers’ ordering practices

18. ACGME Milestone Project

19. Why should we care? • Health system need • Public & physician perceptions skewed • ACGME Next Accreditation System • Residents currently get little or no training • Within the current healthcare system, no real disincentive to curb providers’ ordering practices

20. 2011 AAMC Graduate Questionnaire • 63.8% of students reported inadequate instruction on health economics • 45.9% of students reported inadequate instruction on managed care

21. High Value Care Curriculum • Jointly developed by the ACP and AAIM • Developed in an effort to address the “critical seventh general competency for physicians” http://hvc.acponline.org/

22. High Value Care Curriculum • Initially released in July of 2012 • Newest version released Sept 2013 • can be completed in 6 hours • includes more multimedia content • toolbox to help faculty and program directors measure curricular impact and individual resident performance in high value care http://hvc.acponline.org/

23. ACP's High Value Care (HVC) initiative connects two important priorities: • Helping physicians to provide the best possible care to their patients. 2. Simultaneously reducing unnecessary costs to the healthcare system. http://hvc.acponline.org/

24. Six Curriculum Topics 1. Eliminating Healthcare Waste and Over-ordering of Tests2. Healthcare Costs and Payment Models3. Utilizing Biostatistics in Diagnosis, Screening and Prevention4. High Value Medication Prescribing5. Overcoming Barriers to High Value Care6. High Value Quality Improvement

25. Steps Toward High Value, Cost-Conscious Care4 • Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering • Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful • Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) • Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns • Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste

26. http://hvc.acponline.org/curriculum_list.html

27. Recommendations from more than 50 societies • 30+ societies will announce lists in the next 6 months • Evidence-based recommendations • Consumer Reports is developing and disseminating materials for patients to help patients engage their physicians

29. http://www.choosingwisely.org/

30. What are the potential barriers to high value use of diagnostic tests?

31. What are the potential barriers to high value use of diagnostic tests? • Lack of guidelines • Poor familiarity with guidelines • Lack of knowledge of costs, including the impact of setting on cost • Defensive medicine (i.e. fear of litigation) • Time pressure (emphasis on shorter LOS and productivity) • Explaining to patients why tests/treatments are not indicated • Takes time • Discomfort with diagnostic uncertainty • Local standards of care • Misaligned financial incentives • Lack of appreciation of harms • Patient expectations • Lack of centrally available information on prior tests http://hvc.acponline.org

32. References 1. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163. 2. ACP, ACP’s High-Value Cost-Conscious Care Curriculum. http://hvc.acponline.org/curriculum_list.html 3. Uwe E. Reinhardt blog, NY Times, 12/24/2010. 4. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000-2005. Boston: Health Reform Program, Boston University School of Public Health; 2005. 5. Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009. 6. Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program“; 2012. 7. Adapted from Owens, D. Ann Intern Med. 2011;154:174-180 8. ABIM Foundation, Choosing Wisely Campaign. www.choosingwisely.org 9. Qaseem, A. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147-149 10. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000-2005. Boston: Health Reform Program, Boston University School of Public Health; 2005. • Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009. • Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum. (video) • Association of American Medical Colleges. Medical School Graduate Questionnaire: All Schools Summary Report. Online. https://www.aamc.org

33. Commit to Change

34. Large Group Discussion

35. Teaching Mindfulness:Small group exercise

36. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

37. “Being Mindful”5 Steps Step 1: Did the patient have this test previously? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

38. Step 1 Examples • Transfer from an outside hospital/clinic • Labs/imaging done just prior to transfer • Blood cultures, x-ray, CT, CBC, CMP, etc • Old records • TSH, A1C, anemia w/u, genetic testing • ED • Labs ordered in ED but not yet completed • AM labs ordered (0500) even when labs drawn in ED after midnight

39. “Being Mindful”5 Steps Step 2: Will the result of this test change the care of the patient? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

40. Step 2 Examples • Repeating procalcitonin daily • Repeating CK/CKMB • Frequency of electrolytes/H&H • Ammonia levels • Differential on a CBC • H&H vs CBC, BMP vs CMP, K vs BMP

41. “Being Mindful”5 Steps Step 3: What are the probability and potential adverse consequences of a false positive result? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

42. Step 3 Examples • D-dimer • Troponin • CHF peptide

43. “Being Mindful”5 Steps Step 4: Is the patient in potential danger in the short term if I do not perform this test? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

44. Step 4 Examples • Outpatient testing in the inpatient setting

45. “Being Mindful”5 Steps Step 5: Am I ordering the test primarily because the patient wants it or to reassure the patient? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.

46. Step 5 Examples • MRI for back pain • Repeat CXR in patient’s diagnosed with PNA

47. Commit to Change

48. Resident Assessment of High-Value Care Sarah Richards, MD Kelly Caverzagie, MD

49. Next Accreditation System - Aims • Enhance the ability of our peer-review system to prepare physicians for practice in the 21st century • Reduce the burden associated with the current structure and process-based approach to accreditation • Accelerate the ACGME’s movement towards accreditation on the basis of educational outcomes

50. ACGME Outcomes Project • Introduced 1999 • Implemented 2001 • 6 General Competencies • Medical Knowledge • Patient Care & Procedural Skills • Professionalism • Interpersonal & Communication Skills • Practice-Based Learning & Improvement • Systems-Based Practice