1. The document discusses high value cost conscious care and whether it constitutes rationing or rational care.
2. It notes that health care costs in the US continue to rise significantly each year, with diagnostic imaging being a major driver of increasing costs.
3. Data from 6 large health systems showed large variations in diagnostic imaging rates between different regions without clear clinical benefits, indicating opportunities for more rational use of imaging to improve quality and reduce costs.
[ARCHIVE] Why do people recommend insurance & investment providers? A Global ...Aviva plc
Knowing that a company is stable and secure (stability) is the most likely reason why a consumer would recommend a savings, investments, pensions or an insurance provider. This was one of the findings of the latest wave of the Aviva "Consumer Attitudes to Savings" (CAS) survey.
Designing customer-centric libraries includes challenging traditional library assumptions. This begins with thinking like a customer and breaking down barriers. Rangeview Library District has eliminated fines and implemented WorkThink -a system for organizing materials using words instead of numbers. This new style of library is called Anythink - a place of unlimited imagination, where play inspires creativity and lifelong learning. Anythink is a community space where anything and everything is possible.
[ARCHIVE] Why do people recommend insurance & investment providers? A Global ...Aviva plc
Knowing that a company is stable and secure (stability) is the most likely reason why a consumer would recommend a savings, investments, pensions or an insurance provider. This was one of the findings of the latest wave of the Aviva "Consumer Attitudes to Savings" (CAS) survey.
Designing customer-centric libraries includes challenging traditional library assumptions. This begins with thinking like a customer and breaking down barriers. Rangeview Library District has eliminated fines and implemented WorkThink -a system for organizing materials using words instead of numbers. This new style of library is called Anythink - a place of unlimited imagination, where play inspires creativity and lifelong learning. Anythink is a community space where anything and everything is possible.
LDI Health Policy Seminar with Jeffrey Brenner_ Bending the Cost Curve and Im...
High Value Cost Conscious Care: Is it Rationing or Rational Care? 1_11_13
1. E EM
Q AS
IR
A M
R OM
High Value Cost Conscious
g IS
S IO
N
F
RM
Care: Is it Rationing or
EN
PE
T
IT
Rational C O?WR
R i l Care?R
PRI
O UT
H
IT
W
E
UT Qaseem, MD PhD MHA
Amir Qaseem MD, PhD, MHA, FACP
B
T RI
IS
Director, Clinical Policy, American College of Physicians
D
O R Chair, Guidelines International Network
RE
S HA
NOT
DO
2. E EM
Q AS
IR
Conflicts of Interest A M
R OM
F
N
Financial: SIO
IS
Employee of the American CollegeMof Physicians
ER
P
No other financial conflicts TE N
T
RI
W
OR
RI
Non-financial: UT
P
OH
Guidelines International Network
IT
W
T E
Institute ofUMedicine
B
T RI
Centers for Disease Control and Prevention
IS D
OR
RE
S HA
NOT
DO
3. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
4. E EM
AS
Cost of Health Care in the US A M
IR
Q
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
T
NO
CMS, Office of the Actuary, National Health Statistics Group
DO
5. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT Reinhardt, NY Times, 12/24/2010.
DO
6. E EM
AS
Diagnostic Imaging Studies in 6 LargeMIR Q
A
Integrated Health Care System R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT Smith-Bindman R et al. JAMA. 2012;307:2400-2409.
DO
7. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
8. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
9. E EM
AS
Overtreatment A M
IR
Q
R OM
F
N
IO
Unnecessary treatment IS
S
RM
End of life care PE
T EN
Excessive use of antibiotics R IT
W
Generic vs non-generics OR or higher-priced
PRI
T
services vs l
i lessHexpensive alternates
OU i lt t
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
10. E EM
AS
End of Life: Where Do Patients AMIR Q
Die? OM
FR
N O
Hospital: ~53%
53% SI
IS
E RM
P
Nursing home: ~24% TEN
R IT
W
Home: ~24% OR
PRI
Data f
D t from UT t di
other studies:
th HO
IT
W
T E
Survey
y data: 60-80% of people want to die
U p p
B
at home T RI
IS D
OR
~22%
22%
RE of people die in an ICU
S HA
NOT
Gruneir A et al. Med Care Res Rev. 2007; 64:351
DO
11. E EM
AS
The Cost of Wasted Resources and A M
IR
Q
Unnecessary Diagnostic Testing OM
FR
N O
SI
IS
E RM
Current waste: an estimated N$750 billion loss P
in 2009 (IOM 2012) T TE
RI
W
Inappropriate diagnostic O R testing (i.e. testing
PRI
that is overused or OU
Tmisused) is estimated to
H
IT
cost approximately $210 billion per year (10%
W
E
UT
of annual Ihealth care costs)
B
T R
(PriceWaterhouse (www.pwc.com)
D IS
OR
RE
S HA
NOT
DO
12. E EM
AS
Excess Costs Domain EstimatesAMIR Q
(30% of Health Care Costs) N FR OM
O
Cost in Billions of $$$
Cost in Billions of $$$ SI
IS
E RM
P Unnecessary Services
$75 TEN ($210 B)
$210 R IT Inefficiently Delivered
$55 W
OR
Services ($130 B)
PRI Excess Administrative
$105
$105
O UT Costs ($190 B)
Costs ($190 B)
H Excessive Pricing ($105 B)
IT
W
U TE $130
$130 Missed Prevention
R IB Opportunities ($55 B)
I ST$190 Fraud ($75 B)
D
OR
RE
S HA
NOT The Healthcare Imperative 2010
IOM
DO
13. E EM
AS
According to the IOM report A M
IR
Q
R OM
F
ON
If banking worked like health care, ATM transactions
g , SI
IS
would take days. RM
PE
T EN
If home building were like health care, carpenters,
electricians and plumbers would work f
l ti i d l b ld
R IT k from diffdifferent
t
W
blueprints. OR
PRI
If shopping were like health care, prices would not be
T
posted and could vary H OUwidely within the same store,
IT
W
depending on who was paying.
E
UT
If airline t RIBl were lik h lth care, i di id l pilots
i li travel like health individual il t
T
would beISD free to design their own preflight safety checks
— or OR perform one at all.
E
not p
AR
SH
NOT
DO
14. E EM
AS
Are We Willing (and Able) to AMIR Q
Address the Problem? OM
FR
N O
SI
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
15. E EM
AS
It Is Our Ethical and ProfessionalIR AM
Q
Responsibility to Control Cost! OM
FR
N O
SI
From Medical Professionalism in the New Millennium: A IS
RM
PE
Physician Charter (ABIM-F, ACP-F, EFIM)
EN
“While meeting the needs of individual patients, physicians
T
are required to provide health care R IT that is based on the
W
OR
wise and cost-effective management of limited clinical
resources.” P RI
T
OU
“The physician’s professional responsibility for appropriate
H
IT
allocation of resources requires scrupulous avoidance of
W
E
p UT
superfluous tests and p procedures. The provision of
p
R IB
unnecessary services not only exposes one’s patients to
ST
DI
avoidable harm and expense but also diminishes the
OR
resources available for others.”others.
E
AR
SH
T
OAnn Intern Med. 2002; 136:243-246
N
DO
16. E EM
AS
Physician Controlled Costs A M
IR
Q
R OM
F
N
Unnecessary testing SIO
IS
and treatment $210B RM
PE
Inefficiently delivered
y T EN
R IT
care $130B W
OR
RI
Missed prevention T P
p
opportunities $55B H OU
IT
W
Total = $395B E
UT B
T RI
S
DI
OR
RE
S HA
NOT
DO
17. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
18. E EM
AS
Why is there an overused or A M
IR
Q
misuse? R OM
F
N
Lack of IO
Clinical performance
S
IS
guidance/guidelines measures RM
PE
T EN
Lack of knowledge RIT
Discomfort with
W
R diagnostic uncertainty
Insecurity about IO
PR
clinical skills
li i l kill O UT Discontinuity of care
Di ti it f
H
IT
W
Patient expectations E Inadequate time with
BUT
RI patients
Fear of ST
Imalpractice
D
O R
E Habits
PARPersonal gainl i
S H
T
NO
DO
19. E EM
AS
Financial Incentives Can Drive AMIR Q
Behavior OM
FR
N
Stress Testing Within 30 Days of Outpatient Visit After
O
SI
Coronary R
C Revascularization (%)
l i i IS
M
P ER
EN
30
T T
25 RI
W
OR
RI
20
P
15
O UT Tech+Prof
H Fee
IT
10 W Prof Fee
UTE Only
5
R IB No Billing
ST
0 DI
R
ONo Symptoms CABG PCI Overall
RE
Symptoms
S HA
T
NO BR et al. JAMA. 2011; 306:1993
Shah
DO
20. E EM
AS
Financial Incentives Can Drive AMIR Q
Behavior OM
FR
N O
S SI
A review of ownership of nuclear Imyocardial
perfusion studies among MedicareRM patients:
PE
T EN
cardiologists
cardiologists’ offices increased 215% between
T
RI
1998 and 2006, W
O R
RI
radiologists and other physicians increased 32%
P
T
OU
and 181% respectively
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
T
NO DC et al. J Am Coll Radiol. 2009;6(6):437-441
Levin
DO
21. E EM
AS
Financial Incentives Can Drive AMIR Q
Behavior OM
FR
N O
Self employed
Self-employed urologists (who owned office- SI office
IS
based imaging equipment) were RM2 to 5 times
PE
g ITgT EN
more likely to order imaging for a variety of
y y
R
W
urinary conditions compared with those
OR
urologists who wereP in
g RI employment based
p y
T
OU
practice modelsH(salaried and not owning
IT
equipment)UTE W
B
T RI
S
DI
OR
RE
S HA
T
NO
Hollingsworth JM et al. J Urol. 2010;184(6):2480-2484
DO
22. E EM
AS
Physicians Lack Understanding About BenefitIR
Q
A M
of S
f Screening T
i Tests OM
FR
N
S IO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
OT
Wegwarth O et al. Ann Intern Med 2012;156:340-349
N
DO
23. E EM
AS
Ovarian Cancer Screening: A M
IR
Q
What are the Recommendations? OM
FR
N O
D SI
Routine screening: “D” grade (USPSTF)
IS
E RM
High risk (based on family Ehx.): referral for
N
P
genetic counseling and RITT BRCA testing
W
(USPSTF and ACOG) RI
O R
P
T
+BRCA1 or +BRCA2: candidate f risk-
BRCA1 BRCA2
H OU did t for i k
IT
reducing surgery, not screening (Soc. Gyn.
E
W
UT
Onc.)
Onc ) RIB
T
D IS
O R
E
AR
SH
OT
Baldwin L-M, et al. Ann Intern Med. 2012; 156: 182.
N
DO
24. E EM
AS
Ovarian Cancer Screening: A M
IR
Q
What Do Physicians Think? N FR OM
O
1/3 say transvaginal ultrasound or SI
IS
RM
Ca-125 is an effectiveEscreening PE
N
T
IT
test
t t W
R
OR
Study used case g
y PRI vignettes
T
OU
65% offered ITH screening to medium-risk
W
woman UT E
B
T RI
29%Soffered screening
I to low-risk woman
D
O R
E
AR
SH
OT
Baldwin L-M, et al. Ann Intern Med. 2012; 156: 182.
N
DO
25. E EM
AS
Defensive Medicine A M
IR
Q
R OM
F
N
IO
$45.6
$45 6 billion in 2008 for hospital and IS
S
RM 29: 1569-1577)
physician spending (Mello et al, Health Affairs 2010;
PE
EN
Most common forms (Studdert et T JAMA 2005;293: 2609-2617)
RI
T al
al, 2609 2617)
W
Over-ordering of diagnostic tests O R
PRI
Unnecessary referrals T
H OU
Avoidance of WIT high-risk patients
U TE
R IB
ST
DI
OR
RE
S HA
NOT
DO
26. E EM
AS
Defensive Medicine A M
IR
Q
R OM
F
N
IO
“when doctors order tests procedures or
when tests, procedures,
IS
S
visits, or avoid certain high-risk patients or RM
PE
p
procedures, p , primarily ( ITT
y (but not EN solely) because
y)
R
W
of concern about malpractice liability --- US
OR
g PRI
Congress Office ofT Technology Assessment gy
H OU
Says nothing about the damages that patient
IT
W
T E
could incurUfrom excess or unnecessary y
B
screening T RI
IS D
OR
RE
S HA
NOT
DO
27. E EM
AS
Do Physicians Agree That A M
IR
Q
Healthcare is Overused? R OM
F
N
IO
Survey of primary care physiciansISS
E RM
42% believe patients in theirPown practice
T EN
are receiving too much care (vs 6% who
R IT (vs.
W
say “too little”) O R
PRI
Perceived factors T leading to overuse
OU H
IT
Malpractice W
E
concerns: 76%
UT
Cli i RIB f
Clinical performance measures: 52%
l
S T
DI
Inadequate time to spend with patients: 40%
OR
RE
S HA
NOT Sirovich B et al. Arch Intern Med. 2011; 171:1582-1585
DO
28. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
OT
N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO
29. E EM
AS
Value = Benefits, Harms, Costs AMIR Q
R OM
F
Value = benefit / (cost + harm) SIO
N
IS
Cost ≠ Value RM
PE
EN
Cost includes cost of testTand downstream T
RI
costs, benefits and harms W
O R
PRI
High cost interventions may provide good
T
H OU
value because they are highly beneficial
W
IT
E
Low cost T
Low-costUinterventions may have little or
B
T RI
no value if they provide little benefit or
D IS
R
increase downstream costs.
R E
O
S HA
OT
NOwens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO
30. E EM
AS
Benefit, Cost, and Value A M
IR
Q
R OM
High Benefit F
Low Benefit
N O
SI
IS
M
High Anti-retroviral ER
Routine MRI for low
P
therapy for HIV N
backTpain
E
Cost T
RI
W
Value: high O RValue: low
PRI
O UT
Low HIV screening
H Annual pap smears
IT
Cost W
UTE
R IB
T
Value: high Value: low
D IS
OR
RE
S HA
OT
N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO
31. E EM
AS
Value Measurement: Quality MIR Q
A
Adjusted Life Years (QALYs)ROM
F
N
IO
An important metric for measuring health
S
IS
RM
benefits by taking into accountEboth length
P
N
and quality of life
q y TE
ITR
W
I OR
PR
Allows for comparison of interventions
UT
HO
IT
between different specialities (compare
W
E
UT
cancer treatments with cardiovascular
B
T RI
treatments)
D IS
OR
RE
S HA
NOT
DO
32. E EM
AS
Four interventions, A, B, C, D A M
IR
Q
R OM
F
A is better and cheaper
ND
IO
than
S
IS
E RM
P
TEN
R IT B is better than A b
i b h but
W more expensive
OR
PRI
O UT
H
IT
W
UTE C is better than B but
IB more expensive
T R
S
DI
OR
RE
S HA
OT
N Owens D; Qaseem A et al. Ann Intern Med. 2011; 154:174-180
DO
33. E EM
AS
Cost-Effectiveness Threshold: MIR
Cost- Q
A
How Much is Health Worth?ROM
F
N
Threshold depends on who is making the S IO
IS
decision and their willingness toPpay for better E RM
health outcomes T EN
R IT
National Health Service R in
WUK $30,000-$50,000/
O
QALY PRI
T
No consensus in H USOU - citizens have been willing
IT
W
to pay up to $109,000/QALY, most US decision
E
BUT
k T RI id
makers consider interventions that cost l
i i h less than
h
S
DI
$50,000-$60,000/QALY high value
OR
RE
S HA
T
NO
DO
34. E EM
AS
QALY Examples A M
IR
Q
OM
Intervention Cost Effectiveness N FR Ratio
O
SI
Prevention M
P ti Measures IS
RM
High intensity smoking prevention $190/QALY E P
N
T TE
Screening 60 y o for Diabetes $ RI
$25,738/QALY
W
O R
RI
Treatments for existing
conditions P
T
ART for HIV OU $29,000/QALY
I TH
W
Implantation of defibrillators $52,000/QALY
U TE
oIB
Surgery in 70 y R male with Increased cost and worsens
T
prostate ca DIS health
OR
RE
S HA
T
NO
Cohen JT et al. N Engl J Med 2008;358:661-663
DO
35. E EM
AS
How Can We Reduce A M
IR
Q
Inappropriate Care? R OM
F
N
IO
Develop guidance for physicians Iabout SS
appropriate use of care, focusing RM initially on
PE
diagnostic testing
g g T EN
IT R
Assemble and integrateRevidence-based and
W
O
RI
consensus-based recommendations
P
Ed
Educate t UT
t target audiences about areas of
t HO di b t f
IT
overuse andEmisuse of care:
W
Trainees IB UT
(students, residents, and fellows)
(students residents
T R
IS
www.highvaluecarecurriculum.org
D
R
Practicing clinicians
E
O g
R
APatients
SH
NOT
DO
36. E EM
AS
Key Features of Bringing Cost Consciousness IR
Q
A M
into the T i i E i
i h Training Environment OM
FR
N
Approach: focus on appropriate careS S IO
rather than
I
saving money RM
PE
Knowledge: understanding of EN T
what helps
h ti fl RIT
patients vs. what is superfluous or even harms
ti t W
h
patients OR
PRI
Philosophy: recognition that more ≠ better
T
H OU
Faculty development: trainees mimic faculty
IT
behavior TE W
U
R IB
Assessment: of trainee knowledge and behavior
ST
DI
Regulation: cost consciousness in residency
OR
competency requirements
RE
S HA
NOT
DO
37. E EM
AS
Towards High-Value Cost-Conscious Care
High- Cost- IR
Q
AM
M
Ocare
Ask appropriate questions at the point of
FR
N
Did the patient have this test previously? SIO
IS
RM
Will the result of this test change the care of the
patient? PE
T EN
R IT
What are the probability and potential adverse
W
consequences of a false positive result?
OR
Is the patient in potentialI danger in the short term if I do
PR
not perform thi t Ot?
t f UT
this test?
H
Am I ordering W IT test primarily because the patient
the
wants it orUTEreassure the patient?
to
B
Observe T RIand provide feedback to trainees on
D IS
their
O R provision of high value care- let them
E
AR
H know if they are wasting resources!
S
NOT
DO
38. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
IdentifiesIST clinical situations in which a screening or
37
D
diagnostic test does not reflect high value care.
R O
RE
S HA
T
OQaseem et al. Ann Intern Med. 2012; 156:147-149.
N
DO
39. E EM
AS
Overused Dx Tests A M
IR
Q
R OM
F
Screening for colorectal cancer in adults ON
SI
older than 75 y or in adults withRa life IS
M
PE
expectancy of less than 10 yN
T TE
Performing imaging studies RI in patients with
W
O R
nonspecific low backRIpain P
UT
Ordering routine O H preoperative laboratory
IT
W
tests, including complete blood count, liver
E
UT
chemistryIB TR tests, and metabolic profiles, in f
S
DI
otherwise healthy patients undergoing
OR
l RE ti
elective surgery
HA
S
T
NO
DO
40. E EM
AS
Overused Dx Tests A M
IR
Q
R OM
F
N
Performing brain imaging studies (CT Ior MRI) to IO
SS
evaluate simple syncope in patients RM normal E with
P
findings on neurologic examination N
T TE
Obtaining CT scans in a patient RI with pneumonia that
W
O R
is confirmed by chest radiography in the absence of
RI
P
complicating clinical U T radiographic features
or
H O
Performing imaging IT studies, rather than a high-
W
E
DBUT
sensitivity D-dimer measurement, as the initial
dimer
I
diagnosticRtest in patients with low pretest probability
IS
T
D
of venous thromboembolism
O R
RE
S HA
NOT
DO
41. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
T
OChou R; Qaseem A; et al Ann Intern Med. 2011; 154:181-189
N
DO
42. E EM
AS
Example of Healthcare Waste A M
IR
Q
R OM
F
N
IO
Patient with uncomplicated back pain without IS
S
any red flags RM
PE
EN
Total cost of workup and RITT treatment done in
W
this case (plain films, IMRI, physical therapy):
O R
PR
$10,821.93 T
H OU
IT
Total cost of workup and treatment that would
W
E
UT
be recommended by ACP guideline : $908
IB R
T
DIS
OR
RE
S HA
NOT
DO
43. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
EN T
I addition t measure underuse of care,
In dditi to RdIT f
W
need to develop evidence-based OR
PRI
T
performance measures to assess use of low low-
H OU
value interventions IT
W
E
UT
ServicesIBwhere harm exceeds the zero to
R
ST
negligible benefit
DI
OR
RE
S HA
T
NO Baker D; Qaseem A et al. Ann Intern Med. 2013; 158
DO
44. E EM
AS
Patient Education A M
IR
Q
R OM
Shared-decision making N
F
O
SI
Involve patients and their familiesS M
I
P ER
According to a recent IOM report:
N
E T
69 percent patients want th
t ti t t WR ITi provider t t ll th
their id to tell them
OR
the risks of the treatment options so they will know
PRI
how each might affect them T
OU
53 percent wantHto know about each option’s cost
IT
W
to themselves E and their family.
BUT
47 percent T RI patients want their health care provider
IS
to OR D
discuss the option of not pursuing a test or
tE t
Atreatment
R t
SH
T
OIOM 2012. Communicating with patients on health care evidence.
N
DO
45. E EM
AS
Patient Education A M
IR
Q
R OM
Annals of Internal Medicine Summaries for N
F
O
Patients SI
IS
RM
http://www.acponline.org/clinical_informati PE
T EN
on/guidelines/ R IT
W
ACP Foundation’s Health TiPS OR
PRI
T
Collaborations with consumer
OU
H
IT
organizations (e.g., Consumer Reports)
W
E
that include BUT videos and educational
T RI
IS
materials
D
OR
RE
S HA
NOT
DO
46. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
S T
DI
OR
RE
S HA
N OT
http://www.consumerreports.org/cro/2012/04/best-health-tests-and-treatments-
often-cost-less/index.htm
DO
47. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
48. E EM
AS
Options?? A M
IR
Q
R OM
F
N
IO
Patients share the financial burden
burden… IS
S
RM
PE
Financial incentives for physicians and
T EN
change in the reimbursement system
R IT system….
W
Team-based care….RIO R
P
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
49. E EM
AS
Hurdles?? A M
IR
Q
R OM
F
N
IO
Litigation system IS
S
RM
Transparency (costs, charges,Eetc)N
P
T TE
Heterogeneity in circumstances
RI
W
R
Anecdotal evidence RIO
P
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO
50. E EM
AS
Recommendations for High-
High- IR
Q
A M
V l C -C
Value Cost Conscious C
Cost- i Care FROM
N
S IO
Understand the benefits, harms and relative costs of the
benefits harms, IS
M
interventions that you are considering ER
P
N
Decrease or eliminate the use of interventions that provide
T TE
no benefits and/or may be harmful RI
W
Choose interventions and care O R settings that maximize
P RI
benefits, minimize harms, and reduce costs (using
, T, ( g
OU
comparative effectiveness and cost effectiveness data)
H
IT
W
Customize a care plan with the patient that incorporates
E
their valuesIBUT addresses their concerns
and
R
ST
Identify Isystem level opportunities to improve outcomes,
D
R
minimize harms, and reduce healthcare waste
O
RE
S HA
NOT
DO
51. E EM
Q AS
Issue of the decade starting in 2010: M
IR
A
decreasing the cost of care
f OM
FR
The rise in health care costs is notSION
IS
sustainable RM
PE
Cost containment measures N happenTE will
T
RI
Costs can not be controlled unless
R
W
IO
Rsubstantially reduced
inappropriate care Tis
P
OU
Why should youHcare about cost?
IT
W
Physicians
y U TE
responsible for 87% of spending
p p g
B
RI T
Physicians can be part of the solution or
D IS
R
viewed as part of the problem
R E
O
S HA
NOT
DO
52. E EM
AS
Conserving resources through AMIR Q
M
providing high value care does N
FR
Onot
IO
mean rationing! RM
IS
S
PE
Rationing: decisions are made about the EN
T
allocation of scarce medical
ll ti f diR IT l resources and
d
W
OR
who receives them, leading to underuse of
PRI
potentially appropriate care T
H OU
IT
Rational or high value care: assuring that
E
W
UT
care is clinically effective thus avoiding
RI
B effective,
T
overuse D IS or misuse of care that is
O R
inappropriate
AR
E
SH
OT T; Qaseem A et al. Arch Intern Med. 2012
N Wilt
DO
53. E EM
Q AS
IR
A M
R OM
F
N
SIO
IS
E RM
P
TEN
R IT
W
OR
PRI
O UT
H
IT
W
UTE
R IB
ST
DI
OR
RE
S HA
NOT
DO