Addressing this decade's primary challenge for medical training alguire
Addressing This Decades Primary Challenge for Medical Training Patrick C Alguire, MD, FACP Senior Vice President, Education American College of Physicians
Overview Why is cost consciousness important? Examples of current efforts to control cost What is the current status of cost consciousness during training? What might/should be done?
Overriding Issues inHealth Care Issue of the decade starting in 2000: quality of care and patient safety Issue of the decade starting in 2010: decreasing the cost of care
Cost of Health CareCMS, Office of the Actuary, National Health Statistics Group
Excess Cost Domain EstimatesIOM. The Healthcare Imperative, 2010.
Why are Diagnostic Tests Overusedand Misused? Lack of guidance Insecurity about or guidelines clinical skills Lack of knowledge Discontinuity of Patient care expectations Fear of Inadequate time malpractice Discomfort with Habit uncertainty Personal gain
Overview of Goals for the ACP HVC Initiative Develop guidance for physicians about appropriate use of care, focusing initially on diagnostic testing • Assemble and integrate evidence-based and consensus-based recommendations Educate target audiences about areas of overuse and misuse of care: • Practicing clinicians • Trainees (students, residents, fellows) • Patients
Identifies 37 clinical situations in which a screening or diagnostic test does not reflect high value care.Ann Intern Med. 2012; 156:147-149.
Other National Initiatives National Physicians Alliance: “Top 5” Campaign ABIM Foundation: “Choosing Wisely” Campaign JAMA Internal Medicine (Arch Intern Med): “Less is More” series
Choosing Wisely® Partners ABIM Foundation (convener) American Academy of Allergy, Asthma & Immunology American Academy of Family Physicians American College of Cardiology American College of Physicians American College of Radiology American Gastroenterological Association American Society of Clinical Oncology American Society of Nephrology American Society of Nuclear Cardiology Consumer Reports
What are the current programrequirements re cost-consciousness?Under:IV.F.5.f) Systems-based PracticeResidents are expected to:IV.A.5.f).(3) incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population- based care as appropriate
Are We Educating Residents?(From University of Pennsylvania) 37% of residents were provided some feedback about their resource utilization; 20% reported receiving feedback regularly 16% developed a concrete plan with their attending physician for improving resource utilization; 28% reported receiving any corrective feedback 63% reported having no idea about cost of testsSource: JGME. 2010; 2:175
A Resident’s Perspective on Top 10 Reasons for Over-Ordering 1. How we’re taught 6. Broader ignorance (don’t consider cost) (costs are opaque) 2. Trying to do our best 7. Not realizing how for the patient much setting affects costs (e.g., ER) 3. Pre-emptive ordering 8. Defensive medicine 4. Covering all bases (more=better) 9. Patient requests 5. General lack of 10. Lack of oversight awareness (of cost)Neel Shah. CommonHealth.wbur.org
Coming Your Way Soon! ACGME is increasingly concerned about overuse/misuse of care • How to strengthen current competencies to make programs accountable ABIM is becoming more focused on stewardship of resources • More Items in the certifying and MOC examinations IM-ITE contains “high value care” subscore
Cost-Consciousness andTraining Habits start early in training → need to focus on students, residents, and fellows Joint initiative to develop HVCCC program for residents: AAIM and ACP
Curriculum Dissemination andEvaluation Over 5200 individuals have accessed the curriculum to date Approximately 16% of those accessing the curriculum are residents and students Plan for feedback survey about the curriculum Other metrics: resident survey; program director’s survey; high value care sub- score on the IM ITE
Challenge for Program Directors Focus on cost reduction and minimizing overuse/misuse of diagnostic testing Questions • Why did you order that test? • Was it the most appropriate and cost- effective test to order? • What are you going to do with the results? • Will it change your management?”
The Bottom Line Health care costs are unsustainable Nearly 1/3 of health care costs are wasted Physicians have control over a significant component of these wasted costs Current physician practice and training have not focused on avoiding waste The culture of training must change to assure cost-consciousness and avoiding waste becomes a core value that residents understand and practice