Cost Consciousness Among Medical Practitioners : A Novel Idea?

1. Cost Consciousness Among Medical Practitioners : A Novel Idea? Ari Yeskel PGY-1 Medicine Sinai Hospital, Baltimore June 2013

2. News Goals Market Costs Future Add’l

3. Medical Costs – A Hot Topic

4. News Goals Market Costs Future Add’l

5. Presentation Goals • This is a brief overview of the cost of common diagnostic and treatment modalities in use at Sinai Hospital. Based on data from the April 30, 2013 CDM (chargemaster). • The primary goal is to increase cost awareness among medical practitioners. • Please note, entire courses of study are devoted to medical billing - this presentation provides a brief overview of the process and is by no means complete • Costs presented are the costs billed per the hospital CDM. These costs do not include ancillary fees (e.g., radiology reading, specialty services). • Due to difficulty obtaining pharmaceutical costs, I have eliminated drug costs from this presentation.

6. News Goals Market Costs Future Add’l

7. Is Healthcare a Market Good? • Do you think that healthcare is a market good and is governed by standard laws of supply and demand? A) Yes, dummy, of course B) No, it does not apply to medical care C) Don’t know D) It doesn’t affect me -- I don’t care Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

8. Is Healthcare a Market Good? • Do you think that healthcare should be considered a standard market good? A) Yes, healthcare is no different than any other service B) No, when it comes to health, money should not matter. What is this, socialism? C) Don’t know D) It doesn’t affect me -- I don’t care Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

9. Is Healthcare a Market Good? • Current political and medical debates often refer to our medical care as both a right and as a 'market good' • "In order to consider health care a good that abides by traditional market theory, both consumers and producers should have a reasonable sense of how much the good costs" • What else in our everyday lives do we either buy or sell with complete disregard for cost? • - Clothes • - Food • - Auto repair • - Buying a home • Are we really true market providers? Are patients really consumers? • What happens to the dialogue when healthcare as a market good is broached? Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

10. How are Billable Sinai Hospital Costs Determined? A) It’s a free market, man. Sinai can charge whatever they want and negotiate with insurers B) Government committee sets rates C) Don’t know D) It doesn’t affect me -- I don’t care Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

11. In Maryland Cost Determination is State-Mandated TAKE HOME MESSAGE “The seven-member commission reviews and approves rates that hospitals can charge for their services … …Based on a federal waiver from Medicare, the HSCRC sets rates for all payers: private insurance companies, HMOs, Medicare, and Medicaid. This system is referred to as the "all-payer" system because all payers pay for their fair share of hospital costs.” Sources: Overview of Maryland Regulatory System for Hospital Oversight. From http://mhcc.maryland.gov/consumerinfo/hospitalguide/practitioners/index.htm. May 2013, Zhang, J. Maryland Reins in Hospital Costs by Setting Rates. WSJ. Sept 14, 2009. WSJ.com

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13. Sinai Resident Survey Goal: Conduct brief survey designed to gauge our perception of the costs associated with various procedures, tests, and medications at Sinai Survey: Conducted online through GoogleDocs. Assessed the following costs: CBC, BMP, Lactate, ABG, CK-MB, Troponin, 12-lead EKG, Portable CXR, Head CT, MRI Head, US of LE, and medication costs Response: Total of 17 respondents. Caveats: : Due to a dearth of medication costs within the Sinai Hospital ChargeMaster sheet, medication costs were excluded from the analysis Winner: Stay tuned until end of presentation

14. Sinai Resident Survey

15. Surprisingly, on the whole, residents tend to overestimate costs

16. On average, we overestimated the cost of a CBC by 160%

17. Residents inflate cost of BMP by 90%

18. Sinai residents only mildly inflated lactate costs (22%)

19. We underestimated the true ABG cost by 50%

20. CK-MB estimates were 66% higher than true values (but with exceptionally high std dev)

21. Likewise, troponin estimates were 95% higher than true values (with exceptionally high std dev)

22. 12-Lead EKG Cost Estimates Were 80% Higher Than True Values

23. We overestimated the cost of a portable CXR by 50%

24. Residents’ estimates of CT head exam were 600% higher than the actual cost

25. Our estimates of an MRI were 163% higher than actual cost

26. In contrast to most tests, we underestimated the cost of an ultra sound by nearly $300

27. COPD Patient: Typical Presentation HPI: Mr. ES is a 60 y/o man with COPD, obstructive sleep apnea, and CHF who presents to Sinai with a of a 1 to 2 day history of worsening shortness of breath and mild cough. He had increased orthopnea and diffuse chest discomfort; also some diffuse abdominal pain. The patient is on 3 liters per minute of oxygen at home and nocturnal CPAP for obstructive sleep apnea and is apparently compliant with these. On admission an arterial blood gas showed pH 7.3, PCO2 78, PO2 58. CXR showed no evidence of acute processes and CBC was WNL. During the course of the patient’s ER stay, the patient developed respiratory distress, was placed on BiPAP, IV steroids, bronchodilators, lasix and admitted to the ICU. • Billable items • CXR • ABG • BMP • CBC • Sputum Cx • CPAP (12 hr) • ICU Admission: $60.34 $156.19 $20.17 $14.62 $73.26 $243.13 $ ??? TOTAL (10 minutes) : $568

28. Septic Patient: Typical Presentation HPI: This is a 57-year-old man with short gut syndrome who was transferred to the ICU for hypotension. The patient presented to the hospital on 04/02/2013 with electrolyte imbalance, acute kidney injury associated with dehydration, and increased ileostomy output. His electrolytes were corrected and he was hydrated with improvement in his renal function and he also had GI infections ruled out. He was scheduled for discharge home today, but began having fevers and leukocytosis (peak 51K). He was cultured and started on empiric broad-spectrum antibiotics (and subsequently became hypotensive. Overnight he received IV fluids, but remained hypotensive and was therefore transferred to the ICU for further management and vasopressor support. He also had transient hypoxemia that was felt to possibly be due to volume overload. He was therefore given Lasix. Currently he is feeling well without specific complaints. • Billable items • CXR (portable): • Sputum Cx • Urinalysis • Urine culture • Lactate (q4 x 10) • Blood culture • CBC • BMP $90.47 $73.26 $7.3 $54.9 $36.6 $73.26 $14.62 $20.17 TOTAL (5 minute) : $370.58

29. Daily Blood Draws: Modern-day blood letting ? Sources: Hobson, K. Reducing Unnecessary Blood Tests By Telling Doctors the Cost. WSJ. March 16, 2011. WSJ.com

30. Daily Blood Draws: Costs at Sinai FLOORS Average length of stay* 5.15 days CBC = $14.62 BMP = $20.17 $178 CBC = $14 BMP = $20 Mag = $11 Phos = $3 ICU Average length of stay* 5.15 days $253 Average length of stay* 5.15 days CBC = 2.4ml ** BMP = 4.7ml ** 36ml • Sources: National Center for Health Statistics. Health, United States, 2012: With Special Feature on Emergency Care. Hyattsville, MD. 2013. • Average length of stay in NorthEast = 5.4 days. In South = 4.9. Given Baltimore is in the geographic middle, we take the average of these two values and use 5.15 • **Wisser, D et al. Blood Loss from Laboratory Tests. Clin Chem. 2003 Oct;49(10):1651-5.

31. News Goals Market Costs Future Add’l

32. Next Steps: How can we increase awareness/decrease costs? Add actual antibiotic costs to Sinai antibiogram (in lieu of $$$$) Incorporate ‘cost consciousness’ as a part of medical education (e.g., presentation at orientation, badge additions, lists of common exams) Ordering systems (Hopkins) that show costs when ordering tests, etc. Hypothetical allowance per year for house staff Empowering patients to be active participants in care Changing the system – less disconnect between providers, payers and patients Your input here….

33. Next Steps: (Debatable) Suggestions for Changing Habits Based on Cost • Are serial lactate exams always necessary? • What about (free) anion gap that if normal predicts a normal lactate level and if abnormal predicts an elevated lactate level • Is a BNP always necessary? • Does a good physical exam better predict abnormal heart pressure than a lab test? • For back pain patients, is there a real rationale for an MRI when a CT will suffice? • For COPD patients, what is the role of serial CXRs? Are they necessary? • Other suggestions?

34. News Goals Market Costs Future Add’l

35. Appendix: Imaging - Common Exams

36. Appendix: Costs by common tests by specialty (April 2013)

37. Next Steps: Further Analyses • Obtain detailed cost information from Sinai Pharmacy for most common medications grouped by genre (e.g., cardiac medications, antibiotics) • Create new antibiogram with quantitative costs (per unit) • Create cost awareness cards to be placed on badge with most commonly prescribed tests and associated costs • Suggestions…

38. … AND THE WINNER IS…