“We’re also developing an iPhone app to put cost and quality information at physicians’ fingertips at the critical moment when medical decisions are made,” Dr. Shah adds. “Just being able to see the price variation—an ultrasound versus a CT scan, a generic versus a brand-name medication, or the cost of a marginally valuable test—can help drive physician ordering behavior.”
Robert A. Bessler, MD, CEO of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says his hospitalists spend about $2 million a year “with their pen or computerized physician order entry.” A quarter of the cost is pharmacy-related, and the “majority of the rest is from bed-days.”
“The most expensive thing we do is make the decision to admit,” Dr. Bessler notes. “With hospitals switching from revenue centers to cost centers in a population health/ACO [accountable-care organization] environment, an increasingly important part of the hospitalist’s job will be asking
questions, such as, ‘Could this patient go to a nursing home tonight from the ER?’ and ‘Can my colleague in the post-acute environment take care of this patient, with the same effective outcome, if we provide more intense services in the nursing home, going forward?’”
Because most diagnostic testing is done on the front end of an inpatient’s stay, the hospitalist’s main contribution to cost control is to get that diagnosis right and use consults to answer specific questions, Dr. Bessler explains. “There is a direct correlation between the number of consults and the volume of procedures which lead to higher inpatient costs,” he adds.
As hospitals convert to value-based care models, and pressure increases on hospitalists to ramp up their analysis and sharing of cost data and resource utilization, not all physicians will find that conversion easy.
Just as the patient-safety movement helped caregivers think about how to prevent unintended harm, a new movement is needed to educate doctors, nurses, and other caregivers about the cost and value of their decisions.
—Neel Shah, MD, executive director, Costs of Care
“We are trained to take good care of our patients, not to be financial stewards of the healthcare system,” says SHM Public Policy Committee member Bradley Flansbaum, DO, MPH, SFHM. “Now, physicians are being asked to do both—to watch our resource use without looking like we’re selling out to payors. You’re putting physicians in a difficult position. Will they say to patients, ‘You can’t have this service’? When does being pragmatic stewards of resources become rationing?” he cautions.
Dr. Shah concedes that there is a perceived tension between “what’s best” for my patient and “what’s best” for society. “We, as a profession, haven’t given serious attention to how to navigate those tensions,” he says.
Dr. Flansbaum, a hospitalist at Lenox Hill Hospital in New York City, says it’s time to start down the transparency road.
“Otherwise, we will have a centralized body making these decisions for us,” he says.
Christopher Guadagnino is a freelance medical writer in Philadelphia.