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Cost issues work their way into medical school curricula
Last year, McGraw Hill published a new textbook for medical students, "Understanding Value-Based Healthcare," which focused on how clinicians can deliver better care at lower cost. One of the co-authors of the book, however, Neel Shah, MD, of Harvard Medical School, says it has been a challenge to find schools with space to fit the volume into the curriculum.
Nonetheless, cost issues are working their way into medical study, says Janis Orlowski, MD, chief healthcare officer with the American Association of Medical Colleges (AAMC). “In the past we didn't spend a significant amount of time on costs, but there's been a change. Now, over 90% of medical programs are teaching students about costs,” she says. “Medical schools have always taught quality, but now they are teaching it in a different way, looking at value and saying, 'Does the cost and the quality equal value to the patient?' Something may be valuable but it may also be so costly that other alternatives may be better for the patient.”
Medical students need a basic understanding of costs, be it costs associated with patient copays, or costs associated with treatment decisions. They also need to understand how those costs impact patients and patient compliance, says Orlowski.
Citing the wide range of health plans that practitioners may encounter, she says healthcare finances have become very complicated and that clinicians should not attempt to provide precise information on patients' out of pocket costs. However, she says, they “should have a relative idea of the difference in cost between an X-ray and an MRI, or between a brand name or a generic antibiotic.”
She encourages clinicians to employ a team approach to costs. For example, a patient with diabetes may need to see a podiatrist, an endocrinologist, a physical therapist, and a financial expert who can help them understand costs.
Rick Gutndling, vice president of healthcare financial practices for the Healthcare Financial Management Association (HFMA), says the emerging focus on cost has been a timely development. “Some of the factors driving talk of costs are rising deductibles and employer high-deductible health plans as well as new third-party transparency tools.” He says healthcare customers and patients are becoming “increasingly aware of their out-of-pocket expenditures.”
A recent report by National Public Radio (NPR) highlights an initiative at the David Geffen School of Medicine at UCLA pioneered by Reshma Gupta, MD, that incorporates cost and value discussion into everyday lectures.
But it's not solely a matter of communicating costs to patients, a lot can be done to address costs before they directly impact the patient's wallet or “threaten them with financial ruin,” Shah says.
One problem, he says it is that the medical education environment consistently sends mixed messages to trainees, creating ambiguity about the role costs should play in decisions and treatment options. “We spend lots of time hunting down things that are incredibly rare, but that require extensive and expensive testing to track down. And we are criticized for the things we didn't do, but should have done but you are never ever criticized for things you did that you didn’t have to.”
He says acclimating medical trainees to pursue excessive and exhaustive diagnostic protocols can be counterproductive in their later careers as practitioners. “It is not unusual for a first-year resident to spend hundreds of thousands of dollars ordering tests with the click of a mouse for patients, with no feedback or oversight, and have no idea they spent so much money.”
Correcting this issue could be as straightforward as including an on-screen prompt within medical testing ordering systems apprising trainees of the costs of each procedure, while encouraging vigilance regarding these costs, says Shah.
Shah believes rethinking the diagnostic process can represent a cost-saving practice that can be readily taught in medical school and implemented almost immediately. For example, after Hurricane Sandy isolated Bellevue Hospital and cut its clinicians off from their normal access to diagnostic testing capabilities, Michelle Lin, MD, of New York University Medical School facilitated a project using Bayesian analysis to redesign several care pathways, along the way, discovering more efficient testing strategies that could be replicated by peers.
An initiative by Rob Fogerty, MD, at Yale School of Medicine, takes a different approach to training students to avoid excessive diagnostic testing. Styling the challenge in the form of “a friendly competition,” dubbed, I-CARE, Fogerty presents case studies as a component of daily rounds. He encourages trainees, acting as teams, to compete with one another to arrive at the correct diagnoses at the least expense. Using actual price and cost data, each team presents its workup of the case. To take the lesson home, the team that reaches the correct diagnosis at the lowest expenditure may declare victory.
According to Orlowski, case studies are one way to facilitate “lifelong learning” on cost awareness. “As people go from medical school into their clinical years, they can refer back to those case studies in light of new knowledge, new technologies, policies and costs,” she says.
Shah is founder and executive director of Costs of Care, which sources, curates, and disseminates knowledge from patients and clinicians to help health systems provide high-value care and which is supported by funding from the ABIM Foundation. The organization has developed a project called "Teaching Value," in partnership with AAMC and HFMA. This year, the program plans to recognize seven institutions that have modeled best practices for managing and reducing costs.
AAMC has also partnered with HFMA to develop an innovative workbook on common terms and explanations of financial issues surrounding care costs, says Orlowski, adding that the organization has made the workbook the basis for the work it does with medical schools.
“It continues to be a crowded curriculum,” she says. “We teach the basics in medical school, but most importantly we have to teach students how they can continue to educate themselves in the future.”
David Richardson is an award-winning writer on science and public policy based in Baltimore.