1. Providing High Value Cost Conscious Care:
Providing High Value Cost Conscious Care: Introduction to High Value Care
Bindu Swaroop, MD
Department of Medicine
University of California, Irvine

2. Learning Objectives
Understand some of the current problems with health care spending
Define high value, cost conscious care
Recognize the role that residents, faculty and teaching hospitals play in the problem
Introduce the five step model for delivering high value, cost conscious care
Articulate strategies for bringing high value care into daily practice

3. What is the Problem?
We spend too much on healthcare- $2.6 trillion in 2010, representing 17.6% of the GDP
IOM report in 2009:
About 30 cents of every health care dollar is wasted
$750 billion in inefficient health care spending
"Left unchanged, health care will continue to underperform, cause unnecessary harm, and strain national, state, and family budgets"

4. Wasted Healthcare In 2009: Unnecessary services $210 B
Inefficient services $130 B
Excess administrative costs $190 B
Prices too high $105 B
Missed prevention opportunities $ 55 B
Fraud $75 B

5. Wasted Healthcare In 2009: Unnecessary services $210 B
Inefficient services $130 B
Excess administrative costs $190 B
Prices too high $105 B
Missed prevention opportunities $ 55 B
Fraud $75 B

6. Why Should You Care?
Physicians responsible for 87% of wasteful spending
Previously widely ignored in medical training:
“The reasons for this silence are historical, philosophical, structural, and cultural. ...Combating such forces is a tall order, but I believe that medical educators have an obligation to address cost.”5
- Dr. Molly Cooke

7. Ordering more services3…
Tests
Imaging
Two areas of greatest expenditures and most rapid growth: imaging and tests

8. Reasons Residents Over-Order Tests9
Duplicating role modeled behavior
Desire to be complete
Lack of knowledge of the costs and harms
Pre-emptive ordering/rushing an evaluation/unnecessary duplication of tests
Defensive medicine
Patient requests
Faculty demand
Discomfort with Diagnostic Uncertainty
No training in weighing benefit relative to cost and harm
Curiosity
Ease of access to services when patient is hospitalized
Emphasize the need to create a new culture of accountability where physicians are part of the solution to the rising health care costs by saving dollars in wasted medical expenses

9. .

10. What is High Value, Cost Conscious Care?
Providing the best possible care to our patients and Simultaneously reducing unnecessary costs to the healthcare system

12. Copyright © The American College of Physicians.
All rights reserved.

13. Value, Cost and Health Care
Cost ≠ Value
Cost ≠ Cost of Test
•Cost includes cost of test and downstream costs, benefits and harms
•High-cost interventions may provide good value because they are highly beneficial
•Low-cost interventions may have little or no value if they provide little benefit or increase downstream costs

14. Steps Toward High Value, Cost Conscious Care
Five-Step Framework: High-Value, Cost-Conscious Care
Step 1 Understand the benefits, harms, and relative costs of the interventions that you are considering
Step 2 Decrease or eliminate the use of interventions that provide no benefit and/or may be harmful
Step 3 Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data)
Step 4 Customize a care plan with the patient that incorporates their values and addresses their concerns
Step 5 Identify system-level opportunities to improve outcomes, minimize harms, and reduce health care waste

15. Case Presentation
70 y/o female POD#3 from laparoscopic cholecystectomy
Patient recovering well with plan for discharge
While ambulating became acutely SOB with tachycardia
Complained of right shoulder and chest pain associated with diaphoresis

16. Step 1: Benefits, Harms, Costs
What is your work-up?
What factors lead us to make these orders or recommendations?
How much does this cost?

17. Benefits, Harms, Costs Test Benefit Harm Costs CT Angio TTE EKG
D-dimer
BNP
Troponin (serial)
ABG
LE U/S Doppler
Hypercoagulable work up

18. Benefits, Harms, Costs Test Benefit Harm Costs CT Angio TTE EKG
Best sensitivity for identifying PE
TTE
Assess RV strain
EKG
Identify arrythmia, non-invasive
D-dimer
Easy to obtain, helpful in ruling out PE if negative
BNP
Troponin (serial)
ABG
LE U/S Doppler
no contrast, non-invasive
Hypercoagulable work up

19. Benefits, Harm, Costs Test Benefit Harm Costs CT Angio TTE
Best sensitivity for identifying PE
Contrast, radiation, incidental findings
TTE
Assess RV strain
Low specificity
EKG
Identify arrythmia, non-invasive
D-dimer
Easy to obtain, helpful in ruling out PE if negative
BNP
Troponin (serial)
Repeated phlebotomy
ABG
Arterial Stick
LE U/S Doppler
no contrast, non-invasive
Hypercoagulable work up
Low yield in patient with clear risk factor for PE

20. Benefits, Harms, Costs Test Benefit Harm Costs CT Angio
Best sensitivity for identifying PE
Contrast, radiation, incidental findings
$294.40
TTE
$147.29
EKG
Identify arrythmia, non-invasive
$79.18
D-dimer
Easy to obtain, helpful in ruling out PE if negative
Low specificity
$65.88
BNP
$18.75
Troponin (serial)
Repeated phlebotomy
$26.01 (x 1)
ABG
Arterial Stick
$35.94
LE U/S Doppler
no contrast, non-invasive
$125.23
Hypercoagulable work up
Low yield in patient with clear risk factor for PE

21. Which tests had the potential to change management?
Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful
Which tests had the potential to change management?
-CT Angio
-D-dimer
-Fibrinogen
-BNP
-Serial Troponin
-Hypercoagulable panel
-TTE
-LE Ultrasound
-ABG

22. Which tests had the potential to change management?
Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful
Which tests had the potential to change management?
-CT Angio
-D-dimer
-Fibrinogen
-BNP
-Serial Troponin
-Hypercoagulable panel
-TTE
-LE Ultrasound
-ABG

23. Which tests had the potential to change management?
Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful
Which tests had the potential to change management?
-CT Angio: $294
-D-dimer
-Fibrinogen
-BNP
-Serial Troponin
-Hypercoagulable panel
-TTE
-LE Ultrasound
-ABG
Total Cost: $871.85

24. Step 2: Decrease or eliminate care that provides no benefit and/or may be harmful
Briefly introduce the Choosing Wisely campaign: An initiative of the ABIM. Goal is to promote dialogue between pts and doctors regarding care that is
Evidence-based 2) Necessary 3) Non-redundant 4) Not harmful. For each subspecialty society, lists of 5 things to question were created.

25. Step 3: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs
Use comparative-effectiveness and cost- effectiveness data
In this case: Well’s or Geneva Score to determine pre test probability
Mini Lectures | Residency Program | Residency Program | Department of Medicine | School of Medicine | University of California, Irvine

26. Wells’ Score
Clinical symptoms of DVT (leg swelling, pain with palpation)
3.0
Other diagnosis less likely than pulmonary embolism
Heart rate >100
1.5
Immobilization (≥3 days) or surgery in the previous four weeks
Previous DVT/PE
Hemoptysis
1.0
Malignancy
Traditional clinical probability assessment (Wells criteria)
High
>6.0
Moderate
2.0 to 6.0
Low
<2.0
Simplified clinical probability assessment (Modified Wells criteria)
PE likely
>4.0
PE unlikely
≤4.0

27. Simplified Geneva Score
Variable
Score
Age >65 1
Previous DVT or PE
Surgery or fracture within 1 month
Active malignancy
Unilateral lower limb pain
Hemoptysis
Pain on deep vein palpation of lower limb and unilateral edema
Heart rate 75 to 94 bpm
Heart rate greater than 94 bpm 2
Score of less than 2 is low probablility for PE, score of less than 2 plus a negative D-dimer results in a likelihood of PE of 3%

28. Diagnostic Algorithm
When PE is suspected, the modified Wells criteria should be applied to determine if PE is unlikely (score ≤4) or likely (score >4). The modified Wells Criteria include the following:
Patients classified as PE unlikely should undergo D-dimer testing with a quantitative rapid ELISA assay or a semiquantitative latex agglutination assay. The diagnosis of PE can be excluded if the D-dimer level is <500 ng/mL or negative.
Patients classified as PE likely and patients classified as PE unlikely who have a D-dimer level >500 ng/mL should undergo CT-PA. A positive CT-PA confirms the diagnosis of PE. Alternatively, a negative CT-PA excludes the diagnosis of PE.
In those rare instances in which the CT-PA is inconclusive, either pulmonary angiography or the diagnostic approach intended for institutions without experience in CT-PA can be used.

29. Effective Use of CTA in Setting of Suspected Pulmonary Embolism
By Sasan Sani MD.

30. Methods 40 CTA exams Performed 3/10-3/25 were analyzed retrospectively
55% of these studies were noted to have “PE Rule Out” as their indication
Laboratory and imaging results were reviewed on Quest
Documentation (H&Ps, progress notes, DC summaries,
consultations) were also reviewed on Quest
Well’s Score and Geneva Score were calculated according to the collected data
Data limited by information provided in notes

31. Departments

32. Wells’ Score
Percentage of patients with positive findings in each subcategory. Unfortunately the sample size is small and only two patients had a finding of PE, but these findings are suggestive none-the-less.

33. Wells’ Score
Patients with no finding of PE had an average Wells’ score of 2.4, with a range of Patients with a PE diagnosis had scores of 8 and 10.5.
Only 20% of patients who received a CTA had a Wells’ Score > 4 ( ). D-dimer was not assessed for these patients.

34. Results
Only 2 (9%) out of the 22 CT angiograms performed showed evidence of PE
80% of patients had a Well’s score in the range of “Unlikely PE” (<4)
50% of these patients had a score of <2 (low probability)
D-dimer was checked for only two out of all the patients
one positive D-dimer in setting of PE
one negative in the setting of a negative CTA
Lower extremity ultrasound was also performed for 4 patients (18%)
Only one patient had evidence of DVT, and this patient was diagnosed with PE as well

35. Discussion Previous studies performed have shown similar results
In a cross-sectional study reviewing 589 pulmonary CTA ordered in the emergency department PE was found in 9%
A total of 33% had findings that supported alternative diagnoses
24% had incidental findings that required diagnostic follow up
13% new pulmonary nodule
9% new adenopathy
The conclusion was that CTA was more than twice as likely to find an incidental pulmonary nodule or adenopathy than a PE

36. Conclusion
Patients should be risk stratified appropriately and diagnostic algorithms should be used prior to ordering diagnostic tests
CT angiograms should be utilized in high probability patients or those with suspected PE and a positive D-dimer result

37. Step 4: Customize a care plan with the patient that incorporates their values and addresses their concerns
“And no one thought to get a potassium level?”

38. “And no one thought to get a potassium level?”
Step 4: Customize a care plan with the patient that incorporates their values and addresses their concerns
“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” -Hippocrates ( B.C.)
“And no one thought to get a potassium level?”

39. “And no one thought to get a potassium level?”
Step 4: Customize a care plan with the patient that incorporates their values and addresses their concerns
“It is more important to know what sort of person has a disease than to know what sort of disease a person has.” -Hippocrates ( B.C.)
Patient Centered Care:
“Providing care that is respectful of and responsive to individual patient preferences, needs , values, and ensuring that patient values guide all clinical decisions” (IOM 2001)
“And no one thought to get a potassium level?”

40. Start with the H+P!
The first step is to perform a good history and physical examination
Cost = $0
Risk = Zero
Yield = Priceless

42. Cost of an ED Visit Community hospital in Southern California
Patient fell, seen in ED for evaluation
Clinically stable

43. Quiz: What is the patient charged?
One bag of normal saline given IV: Actual bill: $158.55

44. Quiz: What does is the patient charged?
A comprehensive metabolic panel: Actual bill: $1,212.00

45. Quiz: What is the patient charged?
One set of blood cultures: Actual bill: $510 (remember, we usually order 2 sets)

46. Quiz: What is the patient charged?
Electrocardiogram: Actual bill: $706 (just for the tracing, not including interpretation by a physician)

47. What is the patient charged?
Troponin (x 1): Actual bill: $402 (remember, we usually order x 3)

48. Quiz: What is the patient charged?
CT Head w/o contrast: Actual bill: $2930

49. ED Bill Community hospital in Southern California
Patient fell, seen in ED for evaluation
Clinically stable
Discharged from ED
Total cost billed to patient (not including physician fees): $10,

50. Disclaimer
Cost of test and charge to patient is complex and involves many factors, and is not just monetary
Clinical reasoning and individualized care are very important
Cost-conscious care is not about discouraging appropriate care, nor denying beneficial services

51. Steps Toward High Value, Cost Conscious Care
Five-Step Framework: High-Value, Cost-Conscious Care
Step 1 Understand the benefits, harms, and relative costs of the interventions that you are considering
Step 2 Decrease or eliminate the use of interventions that provide no benefit and/or may be harmful
Step 3 Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data)
Step 4 Customize a care plan with the patient that incorporates their values and addresses their concerns
Step 5 Identify system-level opportunities to improve outcomes, minimize harms, and reduce health care waste

52. Questions to Ask Before Ordering a Test8
Did the patient have this test previously?
Will the result of this test change the care of the patient?
What are the probability and potential adverse consequences of a false positive result?
Is the patient in potential danger in the short term if I do not perform this test?
Am I ordering the test primarily because the patient wants it or to reassure the patient?

54. Summary
START:
•Using validated clinical tools and follow diagnostic algorithms to avoid overuse of tests
•Asking yourself before you order the test if the results will change what you do for the patient
STOP:
•routinely obtaining studies if results will not alter your management

55. References
ABIM Foundation, Choosing Wisely Campaign. (accessed 5/1/12).
Kaniecki R. Headache assessment and management. JAMA.2003;289:
Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, Boston: Health Reform Program, Boston University School of Public Health; 2005.
Cooke M. Cost consciousness in patient care--what is medical education’s responsibility? NEJM. 2010;362:
Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009.
Uwe E. Reinhardt blog, NY Times, 12/24/2010.
Laine C. High-value testing begins with a few simple questions. Ann Intern Med ;156:
Adapted from Neel Shah. Commonhealth. Accessed 10/2011.
Qaseem, A. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost- Conscious Care. Ann Intern Med. 2012;156: