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Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians

Steven E. Weinberger, MD
[+] Article and Author Information

From the American College of Physicians, Philadelphia, Pennsylvania.


Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1081.

Requests for Single Reprints: Steven E. Weinberger, MD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, sweinberger@acponline.org.

Author Contributions: Conception and design: S.E. Weinberger.

Drafting of the article: S.E. Weinberger.

Critical revision of the article for important intellectual content: S.E. Weinberger.

Final approval of the article: S.E. Weinberger.


Ann Intern Med. 2011;155(6):386-388. doi:10.7326/0003-4819-155-6-201109200-00007
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There is general agreement that the U.S. economy cannot sustain the staggering economic burden imposed by the current and projected costs of health care. Whereas governmental approaches are focused primarily on decreasing spending for medical care, it is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of health care costs. At present, the 6 general competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) that drive residency training place relatively little emphasis on residents' understanding of the need for stewardship of resources or for practicing in a cost-conscious fashion. Given the importance in today's health care system, the author proposes that cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new, seventh general competency. This will hopefully provide the necessary impetus to change the culture of the training environment and the practice patterns of both residents and their supervising faculty.

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This is embodied in System-Based Practice
Posted on September 22, 2011
Brian M. Pollak
WellSpan Health
Conflict of Interest: None Declared

The ACGME system-based practice competency is more than teaching quality improvement and being a team player.

From the ACGME's website (http://www.acgme.org/outcome/e- learn/introduction/SBP.html):

"...Residents must be able to utilize resources within the system to provide excellent patient care by:

-demonstrating cost effective resource allocation and prescribing patterns that uphold quality..."

Conflict of Interest:

None declared

Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians
Posted on September 21, 2011
Erik A. Wallace
University of Oklahoma School of Community Medicine
Conflict of Interest: None Declared

TO THE EDITOR: Nine years ago, during my PGY-3 year as an Internal Medicine resident, my attending asked me why I had ordered a test. Unsatisfied with my answer, he followed with the question, "Do you know how much that test costs?" I did not know. He then stated, "Well, then you should pay for it."

At the time I did not know I was being evaluated on the competency of "cost-conscious care and stewardship of resources" proposed by Weinberger (1). However, the lesson I learned that day about cost-conscious care, and the mere $100 test, left an indelible mark on my virtual wallet. I never paid for the test, but my patient and the healthcare system did. Although I lack the power to deduct the cost of unnecessary tests that our residents order from their paychecks, I still use the lesson I learned that day nine years ago to practice and teach cost-conscious care. The reason the lesson worked is that the attending made it personal. If I ordered a test that was unnecessary, then why shouldn't I pay for it?

Our current healthcare system does not hold physicians personally accountable for the judicious use of finite resources. In fact, the majority of physicians have never experienced the inability to pay one's medical bills as most have never lived in poverty. Allopathic medical schools in the United States continue to accept the majority of students from the highest quintile of family income (2). Despite efforts to improve gender and ethnic diversity in medical schools, little has been done to improve socioeconomic diversity of future physicians.

Since most of us have no personal experience with poverty and we are not held accountable for ordering unnecessary tests, our ability to effectively teach cost-conscious care to our residents may be limited. Cost-conscious care, unlike the professionalism and communication competencies, is not a "fundamental attribute" of a high-quality physician and thus cannot be adequately implemented as a core competency through role modeling. Focusing on faculty development of this competency will be essential.

Ideally, a poverty curriculum should be started in medical school, which some schools have already developed (3). If we first teach the competency of "cost-conscious care and stewardship of resources" to our medical students and to our faculty, and we also improve the socioeconomic diversity of our medical students, then implementing this new core competency into residency training will be much more effective.

REFERENCES:

1. Weinberger SE. Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians. Ann Intern Med. 2011;155:386- 388.

2. American Association of Medical Colleges. U.S. Medical School First- Year Enrollment, 2000-2010. Accessed at https://www.aamc.org/download/152934/data/enrollment_data_2010.pdf. Accessed on September 21, 2011.

3. Doran KM, Kirley K, Barnosky AR, Williams JC, Cheng JE. Developing a novel poverty in healthcare curriculum for medical students at the University of Michigan Medical School. Acad Med. 2008;83:5-13.

Conflict of Interest:

None declared

High-Value, Cost-Conscious Care Will Help Advance a Sustainable System
Posted on September 29, 2011
Christine K. Cassel
American Board of Internal Medicine
Conflict of Interest: None Declared

In his commentary "Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians", Dr. Steven Weinberger boldly and eloquently advocated for a new competency that would ensure residents receive formal training and evaluation focused on the avoidance of overuse and misuse of tests and procedures with an aim of reducing health care costs and improving patient outcomes.(1)

While many stakeholders share the responsibility for building a sustainable health care system, physicians will increasingly be held accountable for practicing based on wise decisions about the tests and procedures they order.(2)

Medical Professionalism in the New Millennium: A Physician Charter, published nearly a decade ago by the ABIM Foundation, American College of Physicians Foundation and the European Federation of Internal Medicine and endorsed by more than 130 organizations, including the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, states:

"The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."

There is growing evidence that reducing unnecessary tests and procedures will not only lower health care costs, but will improve patient outcomes. According to research published in a recent Newsweek, while advances in medicine have improved outcomes for many patients, many more receive no benefit, and in some cases may have even been harmed because of them.(3) An investigation by Consumer Reports on heart health found that patients were often overtreated with newer and more expensive tests and procedures that not only did not lead to better outcomes, but sometimes resulted in worse outcomes, when compared to established and cheaper options.(4)

Physicians, practicing in an environment increasingly focused on reducing costs and improving care, will need training to help them make wise decisions about the resources they use. I applaud Dr. Weinberger's proposed new competency for residency training and believe it will help us in advancing a sustainable health care system and improving care for all.

References

(1) Weinberger S. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155:386-388.

(2) ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 136:243-246.

(3) Begley S. One word can save your life: no! The Daily Beast. Accessed at www.thedailybeast.com/newsweek/2011/08/14/some-medical-tests- procedures-do-more-harm-than-good.html on 28 September 2011.

(4) Protect your heart. Consumer Reports. Accessed at www.consumerreports.org/health/conditions-and-treatments/heart- health/heart-disease-treatment/overview.htm on 28 September 2011.

Conflict of Interest:

None declared

Cost-consciousness is constrained by market-based medical practice.
Posted on October 3, 2011
Jeremy D Graham
No Affiliation
Conflict of Interest: None Declared

We read with interest Steven Weinberger's recommendation that cost- consciousness become a seventh core competency in graduate medical education (1). The existing competency of Systems-Based Practice is "manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care..."(2). Arguably, this existing competency already includes cost-consciousness, but in such general language that high costs are largely un-addressed in training and practice. We concur with Dr Weinberger that cost-awareness should be an explicit competency. We additionally emphasize that meaningful cost- conscious behavior by an individual physician is currently constrained by unaddressed structural factors.

Low-value services continue to be a core revenue for market-based medicine. Direct-to-patient advertising functions to increase consumer demand for inappropriate care (3). Health providers and practices profit from the volume of high-cost, low-value care just as do pharmaceutical and device manufacturers.

Secondly, the high costs of medical care include the administration and profit of a fractionated, multi-payer system (4). This overhead-heavy system remains a core impediment to cost-effective care, increasing cost burdens without adding health value.

Lastly, pricing opacity is the norm in market-based medicine, a consequence of medical care being transacted as a market commodity. Charges and costs are often held confidential as trade data, so that costs and values are unavailable to patients. We have previously shown that physicians' own knowledge of medical charges is likewise limited, even within their own specialty area (5).

Cost-consciousness should be promoted to a professional competency. Competence in this regard, however, cannot occur in the current US care delivery environment. To cultivate cost-consciousness into meaningful professional competency, practitioners, teachers and administrators must simultaneously pursue transparent and value-based payment structures for medical care.

Jeremy D Graham MA, DO, FACP Darryl K Potyk MD, FACP Elise D Raimi, MSPH

Citations:

1. Weinberger SE. Providing High-Value, Cost-Conscious Care: A Critical Seventh General Competency for Physicians. Ann Intern Med. 2011( 15)386- 388.

2. Accreditation Council for Graduate Medical Education. Program Requirements: General Competencies. http://www.acme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf Accessed September 28, 2011.

3. Wiles MS, Bell FA, Kravitz RL. Direct-to-consumer prescription drug advertising: trends, impact, and implications. Health Affairs (Millwood) 2000 Mar-Apr;19(2):110-28.

4. Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. . US physician practices versus Canadians: spending nearly four times as much money interacting with payers. Health Affairs (Millwood) 2011 Aug;30 (8):1443-50. Epub 2011 Aug 3

5. Graham JD, Potyk DP, Raimi ER. Hospitalists' awareness of patient charges associated with inpatient care. Journal of Hospital Medicine 2010 (5): 295-297.

Conflict of Interest:

None declared

Cost-consciousness begins at home
Posted on October 3, 2011
Christopher L. Knight
No Affiliation
Conflict of Interest: None Declared

I deeply appreciate Dr. Weinberger's point of view on teaching a cost -conscious approach to care. As a generalist I struggle frequently with uncertainty, balancing my desire for an answer that leaves no doubt with the costs and consequences of excessive diagnostic testing. As an educator I watch students and residents face the same decisions, and I realize that there are countless opportunities to help them reflect on the costs of their choices. This is a real area of opportunity for medical education, and also raises needed questions about professionalism and just allocation of scarce resources, as Dr. Cassel suggests in her comment.

I'm concerned, however, that the College is missing another opportunity for leadership in this regard. Dr. Weinberger focuses on diagnostic testing and hospital readmission, but what about therapeutic choices? For example, the web page on annals.org where I found Dr. Weinberger's abstract contained an advertisement for a new long-acting opiate indicated for "the relief of moderate to severe acute pain in patients 18 years of age or older". I followed the link(1), and found a chart demonstrating that the new drug was equally effective as sustained- release oxycodone, which costs four times less than the new product.(2) I question whether writing a prescription for this new drug would constitute cost-conscious care.

I know that the College does not endorse the use of every product that appears on its web site, in its journals, or in the exhibit halls of its meetings. However, by accepting funds from advertisers and exhibitors the College is endorsing the marketing process. The marketing budgets of many medical products are funded by sales, which in turn are paid for by patients and third-party payors. By using advertising revenues to offset the costs of meetings and publications, the College and all of us who use those resources are benefiting from high costs of care. In a small but important way we have become part of the problem.

It's unrealistic to expect that the College would immediately divorce itself from these funding sources: producing educational materials of the quality of PIER, MKSAP, and the annual Internal Medicine meetings (to name just a few) is breathtakingly expensive, and the quality of those products must not suffer. However, this seems like an opportune moment for the College to develop a strategic plan that would lead to a gradual reduction in industry funding of its educational products, with a long-term goal of eliminating it entirely.

Cost-conscious care is not only a competency for trainees, but one with which we all struggle. By demonstrating a leadership role in reducing industry funding of continuing medical education, the College would show itself willing to make difficult choices in order to reduce costs, and would put itself in a stronger position from which to advocate for high- value care without apparent conflict of interest.

Christopher L. Knight, MD, FACP Seattle, Washington

References:

1. http://www.nucynta.com/nucynta-er/powerful-efficacy-profile (Accessed October 2, 2011) 2. http://www.drugstore.com (Accessed October 2, 2011)

Conflict of Interest:

None declared

Appropriateness consciousness, not cost consciousness
Posted on October 6, 2011
Ira S. Nash
Mount Sinai Medical Center, NY
Conflict of Interest: None Declared

Weinberger's proposal (1) for a seventh competency for physicians is deeply flawed. While it is true that "the US economy cannot sustain the staggering economic burden imposed by the current and projected costs of health care," the key to driving down costs is not "cost-consciousness" but "appropriateness-consciousness."

It is certainly important - as it has always been, as part of sound medical practice - for physicians to avoid "unnecessary care that does not benefit patients," but the imperative to do so is about doing the right thing, not about doing the less expensive thing. It would be important to avoid unnecessary care even if it had no financial cost, since all care always comes with some burden or risk for the patient. Even if the burden is light (the inconvenience of an office visit during work hours), it cannot be justified if there is no expectation of benefit. In addition, risk is often "invisible," and thus underappreciated, but still real. The "unexpected" (and ultimately meaningless) finding on a "harmless" diagnostic test drives more tests of potentially greater hazard and discomfort, affixes an inappropriate label to a patient, and generates anxiety. Better medicine often costs less, but costing less is not what makes it better.

Unfortunately, Weinberger's proposal also reinforces the false notion that any attempt to reign in inappropriate care is just cost-cutting masquerading as quality improvement, and undercuts the credibility of legitimate and important efforts aimed at improving care. Finally, there is real danger down the path of doctors' focusing on goals other than providing the best care for the individual patients in front of them. Such behavior undermines trust, and can lead to putting "collective" goals ahead of individual patient needs, a banner under which any number of atrocities have been perpetrated.(2)

References

1 Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155:386-388.

2 Kevles DJ. The historical contingency of bioethics. Princet J Bioeth. 2000 Spring;3(1):51-58.

Conflict of Interest:

None declared

Cost-Conscious Care Competency is Attainable
Posted on October 21, 2011
Carlos O. Weiss
Michigan State University
Conflict of Interest: None Declared

By proposing "cost conscious care and the stewardship of resources" as a seventh core competency for training in internal medicine, Weinberger underscores the need to better prepare physicians to reduce overuse or misuse of health care services and thereby contribute to the economic sustainability of health care in the U.S.[1] We concur and wish to report lessons learned at one Program of All-Inclusive Care for the Elderly (PACE) site - Hopkins ElderPlus. Like all PACE programs, Hopkins ElderPlus is a comprehensive health care delivery model designed to care for nursing-home eligible people who still live in the community despite high morbidity and functional impairments. Operating under full-financial risk, these capitated programs utilize a well-coordinated inter- disciplinary team (IDT) to achieve desirable outcomes while controlling costs. Although there is significant variability with respect to how each program is organized across the more than 70 programs in 29 states,[2] the solvency of every PACE program depends on cost-conscious care because each program is responsible for all health care costs for its participants.

As with other PACE sites, our main financial challenge lies with overall hospital costs associated with acute illness. We strive to avoid redundant testing and to smoothly and efficiently transition care to a non -hospital setting. When a PACE patient is hospitalized, members of the Hopkins ElderPlus IDT seek to 1) communicate with hospital physicians in writing through a standardized packet, which includes information patients cannot usually recite such as active and recent medications, allergies, plans for life-sustaining treatment and recent medical assessments; 2) notify hospital physicians that the care team, including the primary care physician and social worker, wish to be involved in important patient and family discussions surrounding major procedures or changes in the care plan; 3) perform active retrieval of all test information obtained during hospitalization; and 4) participate in hospital discharge planning. These steps have not been subjected to a controlled experiment, rather they have been developed as a result of continuous real-time monitoring of patient care and financial outcomes. These efforts have improved efficiency in the coordination of care between the inpatient and outpatient setting, which aligns the goals of improving patient care while controlling costs. Indeed, a valuable and necessary core competency.

Conflict of Interest:

MH and MM are employed by Johns Hopkins University and work primarily for Hopkins ElderPlus (PACE). CW was formerly employed in the same manner. HEP is a non-profit health plan receiving capitated funds from Medicare and Medicaid as well as funds from patients.

Author's response to comments
Posted on October 24, 2011
Steven E. Weinberger
American College of Physicians
Conflict of Interest: None Declared

I appreciate the many thoughtful comments in response to my proposal that cost-consciousness be elevated to the level of a 7th general competency for physicians.(1) Dr. Pollak appropriately notes, as I had also mentioned in the paper, that cost-consciousness currently resides within the general competency of systems-based practice. However, as mentioned by Drs. Graham, Potyk, and Raimi, this wording in the training program requirements is very general and does not include sufficient specificity to achieve the intended goal.(2) As I argued in my paper, the inclusion of cost-consciousness under systems-based practice does not give it sufficient visibility or emphasis, considering the current healthcare environment and the importance of effecting a substantial reduction in healthcare costs. I also agree entirely with Dr. Cassel that providing cost-conscious care is part of the professional responsibility of clinicians, as well stated in her comments and in the professionalism charter.(3)

Drs. Graham, Potyk, and Ms. Raimi additionally stress the importance of addressing other components of the health care system that contribute to high costs, including financial drivers for low value services, excessive administrative costs, and lack of transparency in pricing of health care services. I agree that price transparency is critical, so that both physicians and patients understand the costs of the services they are either ordering or receiving. Only with such information can all healthcare stakeholders assess the true value of a service, defined as its benefit relative to its harm, risk, and cost. The PACE (Program of All- Inclusive Care for the Elderly) model described by Drs. Weiss, Holden, and McNabney nicely illustrates how a multi-faceted approach can address some of the other issues that contribute to the high cost of care in a specific population of patients.

In response to Dr. Nash's comment, I fully agree that our primary goal is improving quality of care through "doing the right thing," not just reducing costs. However, I would argue that "cost-consciousness" and "appropriateness consciousness" can be viewed as different ways of describing a largely similar effort. Inappropriate care certainly represents a major, if not the primary, component of the estimated one- third of health care costs that are wasted and do not improve patient care. But focusing purely on quality and on the appropriateness of care does not eliminate the need to understand costs, since physicians and other providers of health care must often choose between comparably appropriate options for care that differ substantially in their costs. I would also stress that an emphasis on cost consciousness in the training environment should not "put collective goals ahead of individual patient needs," but rather should link the goals of best care for each patient with the societal need to reign in the ever-escalating cost of health care.

Dr. Knight raises an important issue about industry funding and its potential impact on continuing medical education and on cost-conscious care. It is indeed essential that there be a strong firewall between revenues that a medical society obtains from industry (e.g., through advertising or exhibits) and the development of any educational content or clinical recommendations/guidelines produced by the society. That principle is sacrosanct at the American College of Physicians, which has a strict policy about relationships with industry that assures not only full disclosure of all commercial support but also absence of any industry influence on educational or clinical content developed by the College.

Finally, Dr. Wallace describes the interrelationships between limited societal resources, limited resources of poor patients, and the need for greater socioeconomic diversity among physicians as well as an understanding of the effect of poverty. The anecdote he provided, where it was suggested that he pay for an unnecessary test, demonstrates well how there may be creative ways to get the attention of residents and change the culture about cost-conscious care in the training environment.

References

1. Weinberger S. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155:386-388.

2. Accreditation Council for Graduate Medical Education. Program Requirements: General Competencies. http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf Accessed October 24, 2011.

3. ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 136:243-246.

Conflict of Interest:

None declared

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