EDITOR’S NOTE: A version of this article originally appeared on Medpage Today on May 5, 2015.
By now, we have all heard the stories about unconscionable medical bills causing financial harm for patients. We have read about more Americans than ever before on high-deductible health insurance plans. Some of us have even helped our parents navigate the deceptively simple-looking bronze, silver, and gold tiers of the insurance exchanges, weighing the gamble of increasingly unaffordable monthly premiums against catastrophically high deductibles and out-of-pocket costs.
We have accepted the fact that healthcare costs are out of control and causing real constraints on every level, from individuals to communities to businesses to states to our nation.
OK, but now what are we supposed to do about it?
“Remarkably, given the importance of this issue, until now, we lacked a roadmap to attack it,” wrote Bob Wachter, MD, in the foreword to our new book, Understanding Value-Based Healthcare. “Now we have one.”
For starters, we can supply a pipeline for change by embedding the principles of value-based care in the apprenticeship of health professional education. Recently, the leaders of the soon-to-open Dell Medical School at University of Texas-Austin articulated their plan to build their entire curriculum around teaching students to root out waste and to care for the health of the community. This is the clearest example that medical educators are taking seriously the calls to action coming from the Accreditation Council for Graduate Medical Education (ACGME), the Association of American Medical Colleges (AAMC), the American College of Physicians (ACP), and other leaders to address healthcare value in training very seriously. However, the front lines are not waiting for new medical schools to open up or for massive curricular overhauls. The Second Annual Teaching Value and Choosing Wisely Challenge that we organized resulted in 80 submissions spanning the country (and Canada). The authors, including five students, 30 residents or fellows, and at least 41 faculty members, described their bright ideas and innovations for integrating healthcare value into education.
Education is fundamental but will not be enough. We must also practice what we preach. Practicing clinicians can deflate medical bills for their patients by advocating for appropriate care, considering patient affordability in customizing treatments, and leading local initiatives to improve value of care.
Clinicians can advocate for appropriate care by avoiding low-value services at the point of care. Specific targets for improving appropriate resource utilization may be identified from resources such as Choosing Wisely lists, guidelines, and appropriateness criteria. Physicians will need to understand the true risks and benefits of recommended therapies and learn ways to communicate this balance with patients.
Patient affordability is increasingly important, with more patients now facing astronomically high out-of-pocket bills, even for simple medical treatments or procedures. A December 2014 CBS/New York Times poll found that 80% of Americans now think their doctor should discuss the cost of recommended medical treatment with them ahead of time. Clinicians can screen their patients for financial harm and can help them navigate the trade-offs of lower cost options. Physicians should seek to provide high-value prescribing, which entails recommending the simplest medication regimen that minimizes physical and financial risk to the patient while achieving the best outcome. In other words, decreasing either cost, complexity, or risk of medications can improve value—and clinicians should aim to improve all three simultaneously.
In addition to reducing waste and considering patient affordability, clinicians are ideal leaders of local value initiatives, whether they accomplish this by running value improvement projects or by launching formal high-value care programs. Our framework to guide value improvement project design is “COST”: culture, oversight accountability, system support, and training. This approach leverages principles from implementation science to ensure that value improvement projects successfully provide multi-pronged tactics for overcoming the many barriers to high-value care delivery. At some locations across the country, individual efforts have matured into entire groups dedicated to designing and implementing value-improvement initiatives, including the UCSF High Value Care Committee, the Johns Hopkins High-Value Care Committee, Johns Hopkins Bayview Physicians for Responsible Ordering (PRO), and “High-Value Carolina” in North Carolina.