Balancing the Value Equation:
Teaching and Assessing
Cost Effective Care
Workshop Goals
• Prepare faculty involved in resident education
to more effectively practice and teach
principles of high-value cost-conscious care
(HVCCC) and assess residents’ ability to
provide HVCCC
• Develop ongoing collaboration between
regional institutions in the area of HVCCC
Workshop Objectives
• Define HVCCC and appreciate its importance
• Identify and understand basic principles of HVCCC
• Recognize resources available to learn about and teach
HVCCC
• Apply principles of HVCCC to your patient care
• More effectively teach principles of HVCCC
• Assess residents’ competency in providing HVCCC using an
assessment tool based on milestones
• Share ideas with colleagues regarding teaching and
evaluation of HVCCC
• Describe potential methods of measuring the impact of an
assessment tool
Introduction Outline
•
•
•
•
•
The value equation
Why should we care?
Review ACP’s High Value Care curriculum
Review Choosing Wisely campaign
Review barriers to high value care
The Value Equation
Benefit
Value =
Cost
Low cost
High cost
No
improved
outcome
Improved
outcome
Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum
Low cost
No
improved
outcome
Improved
outcome
High cost
• Daily labs
• Annual pap smears
• Preoperative CXR in asx
patients
• CHF peptide (BNP)
• MRI for non-specific LBP
• Coronary angiography in
pts with stable chronic
angina
• Sinus CT
• CT/MRI for simple
syncope with normal
neuro eval
•
•
•
•
•
• Anti-retroviral therapy
for HIV
• ICD placement when
meets criteria
Vaccinations
Pap smear
ASA in CAD
Diabetes education
Good history & physical
Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum
Ann Intern Med, 2012
Why should we care?
•
•
•
•
•
Health system need
Public & physician perceptions skewed
ACGME Next Accreditation System
Residents currently get little or no training
Within the current healthcare system, no real
disincentive to curb providers’ ordering
practices
Health System Need
Healthcare costs in the United States are
increasing at an unsustainable rate:
• $253 billion in 1980
• $714 billion in 1990
• $2.6 trillion in 2010
Boston: Health Reform Program, Boston University School of Public Health; 2005
Approximately 30% of Healthcare
Costs are Wasted Care
• $250-325 billion/year
in “unwarranted use”
• $75-100 billion/year
in “provider
inefficiency and
errors”
• $25-50 billion/year in
“lack of care
coordination”
Thomas Reuters, October, 2009
We are ordering more tests…
tests
imaging
Uwe E. Reinhardt blog, NY Times, 12/24/2010.
Physicians are responsible
for 87% of wasteful
spending
Boston: Health Reform Program, Boston University School of Public Health; 2005
Why should we care?
•
•
•
•
•
Health system need
Public & physician perceptions skewed
ACGME Next Accreditation System
Residents currently get little or no training
Within the current healthcare system, no real
disincentive to curb providers’ ordering
practices
Public Perception
Views of US Physicians About Controlling
Health Care Costs, JAMA 2013
• 2556 physicians responded to the survey
• Who has a “major responsibility” for reducing health care costs?
–
–
–
–
–
–
trial lawyers (60%)
insurance companies (59%)
hospitals and health systems (56%)
pharmaceutical and device manufacturers (56%)
patients (52%)
practicing physicians (36%)
• CONCLUSION: “US physicians reported having some responsibility
to address health care costs in their practice and expressed general
agreement about several quality initiatives to reduce cost but
reported less enthusiasm for cost containment involving changes in
payment models.”
Why should we care?
•
•
•
•
•
Health system need
Public & physician perceptions skewed
ACGME Next Accreditation System
Residents currently get little or no training
Within the current healthcare system, no real
disincentive to curb providers’ ordering
practices
ACGME Milestone Project
Why should we care?
•
•
•
•
•
Health system need
Public & physician perceptions skewed
ACGME Next Accreditation System
Residents currently get little or no training
Within the current healthcare system, no real
disincentive to curb providers’ ordering
practices
2011 AAMC Graduate Questionnaire
• 63.8% of students reported inadequate
instruction on health economics
• 45.9% of students reported inadequate
instruction on managed care
• High Value Care Curriculum
– Jointly developed by the ACP and AAIM
– Developed in an effort to address the “critical
seventh general competency for physicians”
http://hvc.acponline.org/
• High Value Care Curriculum
– Initially released in July of 2012
– Newest version released Sept 2013
• can be completed in 6 hours
• includes more multimedia content
• toolbox to help faculty and program directors measure
curricular impact and individual resident performance
in high value care
http://hvc.acponline.org/
ACP's High Value Care (HVC) initiative connects
two important priorities:
1. Helping physicians to provide the best
possible care to their patients.
2. Simultaneously reducing unnecessary
costs to the healthcare system.
http://hvc.acponline.org/
Six Curriculum Topics
1. Eliminating Healthcare Waste and Overordering of Tests
2. Healthcare Costs and Payment Models
3. Utilizing Biostatistics in Diagnosis, Screening
and Prevention
4. High Value Medication Prescribing
5. Overcoming Barriers to High Value Care
6. High Value Quality Improvement
Steps Toward High Value, Cost-Conscious Care4
• Step one: Understand the benefits, harms, and relative
costs of the interventions that you are considering
• Step two: Decrease or eliminate the use of interventions
that provide no benefits and/or may be harmful
• Step three: Choose interventions and care settings that
maximize benefits, minimize harms, and reduce costs
(using comparative-effectiveness and cost-effectiveness
data)
• Step four: Customize a care plan with the patient that
incorporates their values and addresses their concerns
• Step five: Identify system level opportunities to improve
outcomes, minimize harms, and reduce healthcare waste
http://hvc.acponline.org/curriculum_list.html
• Recommendations from more than 50 societies
• 30+ societies will announce lists in the next 6
months
• Evidence-based recommendations
• Consumer Reports is developing and
disseminating materials for patients to help
patients engage their physicians
http://www.choosingwisely.org/
What are the potential
barriers to high value use of
diagnostic tests?
What are the potential barriers
to high value use of diagnostic tests?
• Lack of guidelines
• Poor familiarity with
guidelines
• Lack of knowledge of costs,
including the impact of
setting on cost
• Defensive medicine (i.e. fear
of litigation)
• Time pressure (emphasis on
shorter LOS and productivity)
• Explaining to patients why
tests/treatments are not
indicated
• Takes time
• Discomfort with diagnostic
uncertainty
• Local standards of care
• Misaligned financial
incentives
• Lack of appreciation of harms
• Patient expectations
• Lack of centrally available
information on prior tests
http://hvc.acponline.org
References
1. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
2. ACP, ACP’s High-Value Cost-Conscious Care Curriculum. http://hvc.acponline.org/curriculum_list.html
3. Uwe E. Reinhardt blog, NY Times, 12/24/2010.
4. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000-2005. Boston: Health Reform Program, Boston University School of
Public Health; 2005.
5. Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009.
6. Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program“; 2012.
7. Adapted from Owens, D. Ann Intern Med. 2011;154:174-180
8. ABIM Foundation, Choosing Wisely Campaign. www.choosingwisely.org
9. Qaseem, A. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012;156:147-149
10. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000-2005. Boston: Health Reform Program, Boston University School of
Public Health; 2005.
11.
Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009.
12.
Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum. (video)
12.
Association of American Medical Colleges. Medical School Graduate Questionnaire: All Schools Summary Report. Online. https://www.aamc.org
Commit to Change
Large Group Discussion
Teaching Mindfulness:
Small group exercise
Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
“Being Mindful”
5 Steps
Step 1: Did the patient have this test
previously?
Examples?
Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
Step 1 Examples
• Transfer from an outside hospital/clinic
– Labs/imaging done just prior to transfer
• Blood cultures, x-ray, CT, CBC, CMP, etc
• Old records
– TSH, A1C, anemia w/u, genetic testing
• ED
– Labs ordered in ED but not yet completed
– AM labs ordered (0500) even when labs drawn in
ED after midnight
“Being Mindful”
5 Steps
Step 2: Will the result of this test change
the care of the patient?
Examples?
Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
Step 2 Examples
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•
•
•
•
•
Repeating procalcitonin daily
Repeating CK/CKMB
Frequency of electrolytes/H&H
Ammonia levels
Differential on a CBC
H&H vs CBC, BMP vs CMP, K vs BMP
“Being Mindful”
5 Steps
Step 3: What are the probability and
potential adverse consequences of a false
positive result?
Examples?
Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
Step 3 Examples
• D-dimer
• Troponin
• CHF peptide
“Being Mindful”
5 Steps
Step 4: Is the patient in potential danger in
the short term if I do not perform this test?
Examples?
Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
Step 4 Examples
• Outpatient testing in the inpatient setting
“Being Mindful”
5 Steps
Step 5: Am I ordering the test primarily
because the patient wants it or to reassure
the patient?
Examples?
Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012;156:162-163.
Step 5 Examples
• MRI for back pain
• Repeat CXR in patient’s diagnosed with PNA
Commit to Change
Resident Assessment of
High-Value Care
Sarah Richards, MD
Kelly Caverzagie, MD
Next Accreditation System - Aims
• Enhance the ability of our peer-review system to
prepare physicians for practice in the 21st
century
• Reduce the burden associated with the current
structure and process-based approach to
accreditation
• Accelerate the ACGME’s movement towards
accreditation on the basis of educational
outcomes
ACGME Outcomes Project
• Introduced 1999
• Implemented 2001
• 6 General
Competencies
• Medical Knowledge
• Patient Care &
Procedural Skills
• Professionalism
• Interpersonal &
Communication Skills
• Practice-Based Learning
& Improvement
• Systems-Based Practice
Struggles moving forward…
• Programs had trouble moving from traditional
framework (structure/process) to
competency framework (outcomes)
– Unclear and complex ACGME general
competencies
– Difficulty in assessing and evaluating resident
competence in these general competencies
Think of your training program…
• What outcomes do you expect of your
trainees?
• What are the current outcomes demonstrated
by your trainees?
• What assessments of trainees do you
currently perform?
What are the demonstrated outcomes?
•
•
•
•
Superior? Above average?
Performs better than peers?
Appropriate for level of training?
Trainee confidently tells you how he/she did?
• Do they match your expected outcome?
IOM High Quality Care
• Timely – reducing waits and harmful delay
• Efficient – avoiding waste
• Equitable – providing care that does not vary in quality because of
personal characteristics
• Safe – avoiding injuries from care
• Effective – providing services based on scientific knowledge to all
who could benefit
• Patient-centered – providing care that is respectful of and
responsive to patient preferences, needs and values
Potential Medicare Outcomes
• Work effectively in multiple settings
• Coordinate care within and across settings
• Understand cost and value of diagnostic and
treatment options
• Work in inter-professional teams and multidisciplinary team-based models
• Identify systematic errors and in implement
systematic solutions in case of errors
Internal Medicine Milestones
Family Medicine Milestones
Pediatrics Milestones
University of Nebraska Medical Center
Emergency Medicine Milestones
University of Nebraska Medical Center
Learners
Assessments within
Program:
• Direct observations
• Audit and
performance data
• Multi-source FB
• Chart Stim Recall
• ITExam
Faculty, PDs
and others
Institution
and Program
Accreditation:
ACGME/RRC
Program Aggregation
CCC: Synthesis
and Judgment
Reporting
Milestones
Traditional vs. CBME
Frenk
Lancet, 2010
Entrustable Professional Activity (EPA)
• EPA is a strategy for assessment
• Work-based = reflect the daily work activities of
our profession
• Synthetic = integrate multiple competencies
• Provide context = meaningful assessment of the
work activity
Rules for assessments of trainee:
• Measure the expected outcome(s) for a
defined activity or rotation
• Provide meaning to faculty
• Provide meaning to trainee
• Provide meaning to CCC (in time)
• Reflect needs of our health delivery system
IM-Specific Language
• Curricular Milestones provide granular detail
for focused assessment and feedback
• Reporting Milestones are the outcomes that
document developing competence over the
course of training
UNMC Example –
Hospitalist Medicine Rotation
• Day and night rotation for residents in all three years of
training
• Faculty supervise 1:1 with resident overnight
• Four areas of focus for teaching and assessment:
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–
–
–
High value care
Management of acute care issues (RRT, Code, etc…)
Patient satisfaction
Safe and effective hand-offs at transitions of care
• Other clinical care expectations as well!
Why did we choose these areas of focus?
• High value care
– Nowhere else in residency curriculum, opportunity for
DO, faculty expertise
• Management of acute care issues (RRT’s, codes)
– Opportunity for direct observation by faculty
• Patient satisfaction
– Faculty expertise, opportunity for DO, nowhere else in
residency curriculum
• Safe and effective hand-offs at transitions of care
– Faculty expertise and implement existing tool
Why did we choose these areas of focus?
• High value care
– Nowhere else in residency curriculum, opportunity for
DO, faculty expertise
• Management of acute care issues (RRT’s, codes)
– Opportunity for direct observation by faculty
• Patient satisfaction
– Faculty expertise, opportunity for DO, nowhere else in
residency curriculum
• Safe and effective hand-offs at transitions of care
– Faculty expertise and implement existing tool
Q-Sort: A Game of Competing Priorities
Item 6 – PBLI-D4
Most
important
Independently
appraise clinical
guideline
recommendations for
bias and cost-benefit
Least
important
Choose 22 applicable milestones from the list of 142
71
Combining, Simplifying and/or
Clarifying Similar Milestones
• SBP-E2: Demonstrate the incorporation of cost-awareness
principles into standard clinical judgments and decisionmaking
• SBP-E3: Minimize unnecessary care including tests,
procedures, therapies and ambulatory or hospital
encounters
• Uses cost-awareness principles to minimize the use of tests,
procedures and therapies that provide no benefit or may
be harmful (SBP-E2, SBP-E3)
Integrate Existing Literature
University of Nebraska Medical
Center
What informs the tool?
• Direct observation
• Chart Stimulated Recall
Chart Stimulated Recall
High Value Care Assessment
• Is an EPA (in our context and for our training
program)
• Synthesizes multiple domains of competence
• Provides granular detail for feedback and learning
• Provides meaningful assessment for trainee,
faculty and CCC
Questions?
Thank you!
serichards@unmc.edu
kelly.caverzagie@unmc.edu
Practicing High-Value CostConscious Care:
One Dime at a Time
Lauren Nelson, MD, HO3
Jason Dinsmoor, M4
Practicing High-Value CostConscious Care (HVCCC)
• Understand the cost and benefits
• Decrease unneeded testing
• Use cost and comparative data
• Customize care based on patient
• Identify system level opportunities
for improvement
ACPOnline.org
•Discuss HVC with patient and family
•Identify system improvements
•Minimize unnecessary testing
•Evidence based medicine
Discuss with Patient and Family
• CHOOSING WISELY – IMAGING FOR SYNCOPE
• Does she need a CT scan for detection of an
Aneurysm?
– Lets see what the video says
• Does she need to get this test before her
insurance runs out?
– Lets see what the video says
Discuss with Patient and Family
• Have you ever ordered the test anyways?
• When have you provided HVCCC through
discussion with the patient or family?
• Customize a care plan that incorporates the
patient’s values and addresses concerns
• Think of an example of something a resident
does every day that annoys you?
• Can you think of an example with your
colleagues?
– Annoying?
– Opportunity?
• Identifying System Improvements
Identify System Improvements
•
•
•
•
Collaboration with other specialties
Hospital based projects
Unit based improvement
Resident involvement
Minimize Unnecessary Testing
• First understand interventions you are
considering
• Then decrease/eliminate waste
• CHOSING WISELY – PRE OP CHEST XRAY
• Would you order the CXR?
• What is the potential harm?
• When have you personally minimized
unnecessary testing?
Minimize Unnecessary Testing
What would an intern do….
Minimize Unnecessary Testing
-What teaching points can you offer to the intern
with regards to HVCCC?
-How could physical exam and clinical judgment
prevent the ordering of unnecessary tests?
Medication Reconciliation Exercise
CURRENT HOSPITAL MEDICATIONS
•
•
•
•
•
•
•
•
•
•
•
•
1. Aspirin 325 mg daily
2. Diovan 160 mg daily
3. Crestor 40 mg nightly
4. Coreg 6.25 mg BID
5. Effient 10 mg daily
6. Lantus 35 units SQ nightly
7. Lispro 4 units SQ with meals
8. Glipizide 10 mg daily
9. Metformin 1000 mg BID
10. Nexium 40 mg daily
11. Oxycodone 5mg/Acetaminophen 500 mg q4 hours PRN
12. Docusate 100 mg BID
Medication Price Resources
• www.costco.com
• www.epocrates.com
• www.goodrx.com
Evidence Based Medicine
• CHOOSING WISELY – D-DIMER FOR VTE
• What tools did the attending use to teach the
resident?
• What techniques do you use?
• http://www.choosingwisely.org/doctorpatient-lists/
Summary
• Practicing High-Value Care is the future!
– Practice it well
– Teach it well
– DIME
• You can make a difference
– Even if it is “One Dime at a Time!”
Questions
References:
• High Value Care. American College of Physicians, 20 September 2013
http://hvc.acponline.org/
• Doctor-Patient-Lists. Choosingwisely, 20 September 2013
<http://www.choosingwisely.org/doctor-patient-lists/>
• D-Dimer for VTE. Choosingwisely. 20 September 2013 <http://bcove.me/o25uikla>
• Pre-Op Chest X-ray. Choosingwisely. 20 September 2013 <http://bcove.me/ad4fkrf6>
• Imaging for Syncope. Choosingwisely. 20 September 2013
<http://bcove.me/m0d33op8>
Thank You!