Bryn Nelson, PhD

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

“Number one, they came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources,” says Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer for the Association of American Medical Colleges. “So we found that problematic, given all the evidence we have of the growing, aging population.”

Census figures indeed suggest a rapidly growing population of seniors: By 2030, one in five U.S. residents will be at least 65 years old. The estimated size of a future doctor shortage, however, has proven far more contentious.

Vikas I. Parekh, MD, FACP, SFHM, chair of the SHM Academic Hospitalist Committee, says most observers agree on a few basic points: that the pool of U.S. physicians leans more toward specialty than primary care and that significant workforce gaps exist in certain geographic locations—both in primary care and in other specialties.

Dr. Grover says the uneven distribution and an overall shortfall are both problematic; the AAMC has projected a shortage of up to 90,000 doctors by 2025. But Dr. Parekh says predicting future workforce numbers has always been a challenge.

“Historically, the projections of what the shortages might be have not been reliable or accurate,” he says.

In a recent outlook published by the National Institute of Healthcare Management, IOM committee co-chair Gail Wilensky, PhD, a senior fellow at Project HOPE and former Medicare administrator, goes a step farther. “We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past,” she writes. “In fact, past projections have not always been even directionally correct.”

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and another IOM committee member, likewise defended the report’s analysis.

“I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that,” she writes in an e-mail to The Hospitalist. “Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable.

“However, we were agreed, and stated multiple times, that there were and are striking physician shortages by geography and specialty in multiple areas of the country, and we suggested a specific system change aimed at beginning to address these geographic and specialty shortages.”

The committee members decided against the “one size fits all” solution of simply expanding the current system, she says, because they believed the existing structure had contributed to the disparities in the first place.

ROBERT FOGERTY, MD, MPH, a hospitalist and assistant professor of medicine at Yale University, talks about how his own bout with cancer as a college senior heading to medical school helped influence his I-CARE education initiative, which introduces cost awareness into internal medicine residency programs.

ROBERT FOGERTY, MD, MPH, a hospitalist and assistant professor of medicine at Yale University, talks about how his own bout with cancer as a college senior heading to medical school helped influence his I-CARE education initiative, which introduces cost awareness into internal medicine residency programs.

ROBERT FOGERTY, MD, MPH, a hospitalist and assistant professor of medicine at Yale University, talks about how his own bout with cancer as a college senior heading to medical school helped influence his I-CARE education initiative, which introduces cost awareness into internal medicine residency programs.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

CHRISTOPHER MORIATES, MD, assistant clinical professor in the Division of Hospital Medicine at the University of California, San Francisco, talks about the change in focus and priorities needed for medicine to make progress in waste-reduction efforts.

For Robert Fogerty, MD, MPH, it’s more than just a story. It’s a nightmare that he only narrowly avoided.

Now a hospitalist at Yale University School of Medicine in New Haven, Conn., Dr. Fogerty was an economics major in his senior year of college when he was diagnosed with metastatic testicular cancer. Early in the course of his treatment, amid multiple rounds of chemotherapy and before a major surgery, his insurance company informed him that his benefits had been exhausted. Even with family resources, the remaining bills would have been crippling. Luckily, he went to college in Massachusetts, where a state law allowed him to enroll in an individual insurance plan by exempting him from the normal pre-existing condition exclusion. Two years later, he got his life back in order and enrolled in medical school.

“What stuck with me is, yes, I was sick, and yes, I lost all my hair, and yes, I went to my final exams bald with my nausea medicine and my steroids in my pocket and all of those things,” he says. “But after that was all gone, after my hair grew back, and I had my last chemo and my surgery, and I was really starting to get my life back on track, the financial implications of that disease were still there. The financial impact of my illness outlasted the pathological impact of my illness, and the financial burdens could easily have been just as life-altering as a permanent disability.”

Although he was “unbelievably lucky” to escape with manageable medical bills, Dr. Fogerty says, other patients haven’t been as fortunate. That lesson is why he identifies so much with his patients. It’s why he posted his own story to the Costs of Care website, which stresses the importance of cost awareness in healthcare. And it’s why he has committed himself to helping other medical students and residents “remove the blinders” to understand healthcare’s often devastating financial impact.

“When I was going through my residency, I learned a lot about low sodium, and I learned a lot about bloodstream infections and what to do when someone can’t breathe and how to do a skin exam, and all of these things,” Dr. Fogerty says. “But all of these other components that were so devastating to me as a patient weren’t really a main portion of the education that we’re providing tomorrow’s doctors. I thought that was an opportunity to really change things."

By combining his clinical and economics expertise, Dr. Fogerty helped to develop a program called the Interactive Cost-Awareness Resident Exercise, or I-CARE. Launched in 2011, I-CARE seeks to make the abstract problem of healthcare costs—including unnecessary ones—more accessible to trainees. The concept is deceptively simple: Residents compete to see who can reach the correct diagnosis for a given case using the fewest possible resources.

By talking through each case, both trainees and faculty can discuss concepts like waste prevention and financial stewardship in a safe environment. Giving young doctors that “basic set of vocabulary,” Dr. Fogerty says, may help them engage in real decisions later on about a group or health system’s financial pressures and obligations.

The program has since spread to other medical centers, and what began as a cost-awareness exercise has blossomed into a broader discussion about minimizing the cost and burden to patients while maximizing safety and good medicine. TH

For Robert Fogerty, MD, MPH, it’s more than just a story. It’s a nightmare that he only narrowly avoided.

Now a hospitalist at Yale University School of Medicine in New Haven, Conn., Dr. Fogerty was an economics major in his senior year of college when he was diagnosed with metastatic testicular cancer. Early in the course of his treatment, amid multiple rounds of chemotherapy and before a major surgery, his insurance company informed him that his benefits had been exhausted. Even with family resources, the remaining bills would have been crippling. Luckily, he went to college in Massachusetts, where a state law allowed him to enroll in an individual insurance plan by exempting him from the normal pre-existing condition exclusion. Two years later, he got his life back in order and enrolled in medical school.

“What stuck with me is, yes, I was sick, and yes, I lost all my hair, and yes, I went to my final exams bald with my nausea medicine and my steroids in my pocket and all of those things,” he says. “But after that was all gone, after my hair grew back, and I had my last chemo and my surgery, and I was really starting to get my life back on track, the financial implications of that disease were still there. The financial impact of my illness outlasted the pathological impact of my illness, and the financial burdens could easily have been just as life-altering as a permanent disability.”

Although he was “unbelievably lucky” to escape with manageable medical bills, Dr. Fogerty says, other patients haven’t been as fortunate. That lesson is why he identifies so much with his patients. It’s why he posted his own story to the Costs of Care website, which stresses the importance of cost awareness in healthcare. And it’s why he has committed himself to helping other medical students and residents “remove the blinders” to understand healthcare’s often devastating financial impact.

“When I was going through my residency, I learned a lot about low sodium, and I learned a lot about bloodstream infections and what to do when someone can’t breathe and how to do a skin exam, and all of these things,” Dr. Fogerty says. “But all of these other components that were so devastating to me as a patient weren’t really a main portion of the education that we’re providing tomorrow’s doctors. I thought that was an opportunity to really change things."

By combining his clinical and economics expertise, Dr. Fogerty helped to develop a program called the Interactive Cost-Awareness Resident Exercise, or I-CARE. Launched in 2011, I-CARE seeks to make the abstract problem of healthcare costs—including unnecessary ones—more accessible to trainees. The concept is deceptively simple: Residents compete to see who can reach the correct diagnosis for a given case using the fewest possible resources.

By talking through each case, both trainees and faculty can discuss concepts like waste prevention and financial stewardship in a safe environment. Giving young doctors that “basic set of vocabulary,” Dr. Fogerty says, may help them engage in real decisions later on about a group or health system’s financial pressures and obligations.

The program has since spread to other medical centers, and what began as a cost-awareness exercise has blossomed into a broader discussion about minimizing the cost and burden to patients while maximizing safety and good medicine. TH

For Robert Fogerty, MD, MPH, it’s more than just a story. It’s a nightmare that he only narrowly avoided.

Now a hospitalist at Yale University School of Medicine in New Haven, Conn., Dr. Fogerty was an economics major in his senior year of college when he was diagnosed with metastatic testicular cancer. Early in the course of his treatment, amid multiple rounds of chemotherapy and before a major surgery, his insurance company informed him that his benefits had been exhausted. Even with family resources, the remaining bills would have been crippling. Luckily, he went to college in Massachusetts, where a state law allowed him to enroll in an individual insurance plan by exempting him from the normal pre-existing condition exclusion. Two years later, he got his life back in order and enrolled in medical school.

“What stuck with me is, yes, I was sick, and yes, I lost all my hair, and yes, I went to my final exams bald with my nausea medicine and my steroids in my pocket and all of those things,” he says. “But after that was all gone, after my hair grew back, and I had my last chemo and my surgery, and I was really starting to get my life back on track, the financial implications of that disease were still there. The financial impact of my illness outlasted the pathological impact of my illness, and the financial burdens could easily have been just as life-altering as a permanent disability.”

Although he was “unbelievably lucky” to escape with manageable medical bills, Dr. Fogerty says, other patients haven’t been as fortunate. That lesson is why he identifies so much with his patients. It’s why he posted his own story to the Costs of Care website, which stresses the importance of cost awareness in healthcare. And it’s why he has committed himself to helping other medical students and residents “remove the blinders” to understand healthcare’s often devastating financial impact.

“When I was going through my residency, I learned a lot about low sodium, and I learned a lot about bloodstream infections and what to do when someone can’t breathe and how to do a skin exam, and all of these things,” Dr. Fogerty says. “But all of these other components that were so devastating to me as a patient weren’t really a main portion of the education that we’re providing tomorrow’s doctors. I thought that was an opportunity to really change things."

By combining his clinical and economics expertise, Dr. Fogerty helped to develop a program called the Interactive Cost-Awareness Resident Exercise, or I-CARE. Launched in 2011, I-CARE seeks to make the abstract problem of healthcare costs—including unnecessary ones—more accessible to trainees. The concept is deceptively simple: Residents compete to see who can reach the correct diagnosis for a given case using the fewest possible resources.

By talking through each case, both trainees and faculty can discuss concepts like waste prevention and financial stewardship in a safe environment. Giving young doctors that “basic set of vocabulary,” Dr. Fogerty says, may help them engage in real decisions later on about a group or health system’s financial pressures and obligations.

The program has since spread to other medical centers, and what began as a cost-awareness exercise has blossomed into a broader discussion about minimizing the cost and burden to patients while maximizing safety and good medicine. TH

A trickle of anecdotes has become a flood of cautionary tales.

There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”¹

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.²

In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.³ A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.² If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

A Culture of “More”

What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:

• Physician training and culture;
• The fee-for-service payment structure;
• Aggressive marketing by developers of tests, drugs, and procedures;
• Defensive medicine;
• A cultural preference for technological solutions; and
• A lack of transparency on the true costs of care.

The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”

A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.

At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.

“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”

Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.

“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.

Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.

“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.

High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.

The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.

I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco

“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.

Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”

As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.

“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”

It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”

Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.

Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.

Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?

More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver

After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.

Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.

Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.

“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”

In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.⁴

Signs of Progress

Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.

Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.⁵

“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.

The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.

“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.

In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.⁶ By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.

Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care

To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.⁷

First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.

Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.

Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.

“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”

Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.

Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.

“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”

Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.

“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”

Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
2. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
3. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
4. Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
5. Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
6. Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
7. Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.

A trickle of anecdotes has become a flood of cautionary tales.

There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”¹

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.²

In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.³ A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.² If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

A Culture of “More”

What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:

• Physician training and culture;
• The fee-for-service payment structure;
• Aggressive marketing by developers of tests, drugs, and procedures;
• Defensive medicine;
• A cultural preference for technological solutions; and
• A lack of transparency on the true costs of care.

The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”

A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.

At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.

“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”

Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.

“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.

Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.

“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.

High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.

The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.

I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco

“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.

Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”

As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.

“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”

It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”

Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.

Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.

Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?

More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver

After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.

Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.

Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.

“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”

In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.⁴

Signs of Progress

Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.

Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.⁵

“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.

The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.

“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.

In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.⁶ By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.

Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care

To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.⁷

First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.

Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.

Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.

“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”

Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.

Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.

“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”

Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.

“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”

Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
2. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
3. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
4. Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
5. Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
6. Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
7. Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.

A trickle of anecdotes has become a flood of cautionary tales.

There’s one about the patient in intensive care who didn’t have a cardiac condition yet still had a troponin blood test on 26 consecutive days. Guidelines, of course, suggest that three tests in a 12- to 24-hour period are sufficient to diagnose or rule out a heart attack.

Here’s another: A schizophrenic patient complaining of abdominal pain was sent to the ED. After a normal CT scan, she was admitted to the hospital for further workup and pain control. Amid discussions over whether the doctors should order an MRI or surgery consultation, a review of her records revealed 40 CT scans over the previous five years. All had turned up nothing, and the patient’s family confirmed that her frequent bouts of abdominal pain went away on their own.

Then there’s the story about a middle-aged man with an asthma diagnosis from years before; he was scheduled for surgery to correct his painful umbilical hernia. As part of the patient’s evaluation in a pre-operative clinic, his surgeon ordered a chest X-ray (CXR), despite a lack of any respiratory symptoms. The results suggested a possible lung nodule, leading to a follow-up CT scan that revealed normal lungs but instead showed a potential adrenal gland nodule. A second CT scan showed only a benign lesion, but the series of false alarms effectively delayed his hernia surgery by six months.

In the subsequent report on the latter case, included in the “Teachable Moments” section of JAMA Internal Medicine, the co-authors concluded, “Despite the evidence that pre-operative CXR is unlikely to be beneficial, it continues to be used in daily practice. Exposing a patient to multiple, additional studies prolongs surgical delay, increases exposure to radiation, prolongs and exacerbates underlying anxiety, and increases the likelihood of additional incidentalomas.”¹

Unnecessary overuse of medical care, in other words, can cause both waste and harm.

Some of the stories highlight egregious examples, while others meditate on more nuanced cases. All are zeroing in on needlessly wasteful healthcare that can negatively impact patients physically, emotionally, and financially.

“I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false,” says Christopher Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California, San Francisco.

Increasingly, like-minded hospitalists and other physicians are launching groups and projects around the country with names like Caring Wisely, Providers for Responsible Ordering, Costs of Care, the Do No Harm Project, and I-CARE. Each group takes a slightly different approach toward reframing clinical decisions in a way that considers both the potential benefit and the accompanying risks and costs.

The Caring Wisely program, which Dr. Moriates leads, supports innovations that reduce healthcare costs while improving patient health. The nonprofit organization Costs of Care, meanwhile, is trying to change professional norms by pointing out the ethical downsides of overuse.

“I’ve never heard anybody get called unethical for wasting a healthcare resource, but that’s where we need to go,” says Neel Shah, MD, MPP, founder and executive director of Costs of Care and an assistant professor at Harvard Medical School in Boston.

This dogma-challenging, evidence-based, awareness-raising movement is building momentum at a critical time. Although the problem of wasteful healthcare isn’t unique to the United States, multiple experts have pointed out the big disconnect between the nation’s top ranking in per capita healthcare spending and only middling scores in a long list of healthcare outcomes.²

In their damning 2008 commentary, “The Perfect Storm of Overutilization,” National Institutes of Health bioethicist Ezekiel Emanuel, MD, PhD, and Stanford economist Victor Fuchs, PhD, laid out the argument that overutilization was the most important contributor to high healthcare costs in the U.S.³ A greater volume of interventions and unnecessary costs both contributed to this overuse, the authors suggested.

Subsequent reports by Thomson Reuters in 2010, an Institute of Medicine (IOM) roundtable on evidence-based medicine in 2011, and the RAND Corporation in 2012 largely agreed. Based on its report, “The Healthcare Imperative: Lowering Costs and Improving Outcomes,” the IOM laid out a particularly sobering analogy to the degree of waste found in medical care.² If other prices had grown as quickly as healthcare since 1945, the report estimated, a gallon of milk would now cost $48. Yet, of the $2.5 trillion spent on healthcare in 2009, the report estimated that 30%, or $765 billion, was wasted. Of that number, the report suggested that unnecessary healthcare services accounted for $210 billion, or 27%.

A Culture of “More”

What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:

• Physician training and culture;
• The fee-for-service payment structure;
• Aggressive marketing by developers of tests, drugs, and procedures;
• Defensive medicine;
• A cultural preference for technological solutions; and
• A lack of transparency on the true costs of care.

The authors contend that each factor reinforces and amplifies the others, resulting in a “perfect storm of ‘more.’”

A major driver, several doctors agree, is a culture that has long embraced the “more is better” mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: “More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better.” A collective “cultural blind spot,” he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.

At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.

“Diagnostic uncertainty really feeds into a system where we have ready access to lots of things,” Dr. Combs says. “We have such a supply of tests, whether that’s blood tests, whether that’s imaging tests, whether that’s access to consultations with subspecialists—we have a system that can supply whatever demand we seem to have.”

Dr. Shah calls it a “hidden curriculum” that imposes its will on doctors’ discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.

“When you’re criticized by your colleagues or by your mentors, it’s always for things that you didn’t do but could’ve done, and it’s never about the things that you did do but didn’t have to,” he says.

Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20th century.

“You learn to do things the way they’ve always been done,” he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. “That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study,” he says.

High-value care is now emerging as a third outgrowth along the medical training pathway. “It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less,” Dr. Accurso says.

The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that’s constantly in flux.

I think for a long time we thought, ‘Might help, can’t hurt,’ and we’re seeing time and time again that that is just totally false. —Christopher Moriates, MD, assistant clinical professor, division of hospital medicine, University of California, San Francisco

“Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more,” says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.

Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. “Because there’s so much that we don’t know, sometimes we like to ask more questions by ordering more tests to try and find the answer,” Dr. Fogerty says. “So it’s almost an endless quest for knowledge, an endless hope that the answer’s under some rock if we just turn over enough rocks.”

As reform advocates are finding, however, even ample evidence isn’t always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.

“I feel very strongly, actually, that for physicians to improve the value of care we’re delivering, it doesn’t require a new set of knowledge,” he says. “It doesn’t require training in health policy or health economics; it’s stuff that we already know.”

It may require intervention before practice patterns become deeply engrained, however. According to Medscape’s Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, “No, because these guidelines are not in the patient’s best interest,” while 24% said, “No, because I am still going to practice defensive medicine.”

Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. “We don’t have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order—how those tests can influence our clinical management,” she says.

Dr. Accurso agrees. “My recollection of my training, which would have only been seven years ago, is that there wasn’t much discussion of when not to order,” he says.

Although defensive medicine and the fee-for-service payment structure clearly aren’t helping anti-waste efforts, Dr. Shah says they’re often used as excuses to mask other issues. Residents in an academic medical center, for example, don’t make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?

More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I’m getting more, if I’m spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better. —Brandon Combs, MD, assistant professor of medicine, University of Colorado School of Medicine, Denver

After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.

Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.

Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.

“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”

In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.⁴

Signs of Progress

Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.

Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.⁵

“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.

The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.

“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.

In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.⁶ By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.

Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care

To help disseminate its own message, the Providers for Responsible Ordering (PRO) group at Johns Hopkins has handed out pocket cards summarizing best practice guidelines, compiled literature reviews, and other educational resources on its website. One recent PRO-backed project used a three-phase process to dramatically reduce unnecessary cardiac enzyme testing at the medical center.⁷

First, the group gave physicians informational pocket cards. Next, one of the group’s leaders, assistant professor of medicine Jeffrey Trost, MD, gave grand rounds and presented guidelines suggesting no creatine kinase (CK) or CK-MB tests for patients suspected of having acute coronary syndrome, and no more than three troponin tests except in rare circumstances. Finally, the medical center removed CK and CK-MB altogether from its standard physician order entry. As a result, the total orders fell by 66% in the first year, saving an estimated $1.25 million in patient charges.

Internal medicine resident Sonali Palchaudhuri, MD, another PRO member at Hopkins, says an evidence-based approach isn’t always simple. “But our goal with PRO is, 1) to make sure that the evidence is at everyone’s fingertips to at least tailor their decisions based on the evidence that’s out there, and 2) to encourage an environment where we are looking for the evidence more than remaining in the state of practice [that existed] before we knew some of the newer data,” she says.

Other efforts like the Do No Harm Project are helping both medical trainees and attending doctors “celebrate restraint” by emphasizing problem solving that focuses more on what is probable than on what is possible.

“On rounds, an attending might say, ‘Why didn’t you order that or do that?’” Dr. Combs says. “Sometimes, it’s the right thing to do. But not often enough do we say, ‘Good job. I’m glad that you didn’t get that, because that wasn’t necessary, and here’s why.’”

Researchers, meanwhile, are helping to sharpen the distinctions between low and high-value care. “The progression has been first to define what constitutes low-value care, then develop measures of low-value care, both to understand its prevalence and to what extent it’s a problem,” says William Schpero, a PhD student in health policy and management at Yale University. The next step, he says, will be using these measures to inform and evaluate quality improvement efforts at the hospital or clinic level and to provide feedback for physicians working to reduce low-value care within their practices.

Many physicians warn that diplomacy and good communication are essential for getting buy-in from providers. Instead of framing their projects as efforts to reduce unnecessary care, for example, Dr. Moriates and colleagues have described them as stewardship projects designed to ensure that providers are following the best guidelines and providing exceptional patient care.

“Suddenly, everybody can rally around that, because everybody wants to provide the best care,” he says. “And so you’re giving people an opportunity to give the best care rather than taking away something that they have, like transfusions.”

Likewise, framing an issue primarily in financial terms without emphasizing its toll on patients can put many physicians on the defensive.

“We don’t like to think of ourselves as being motivated by cost,” Dr. Combs says. He also urges caution when discussing high-value care. “When a person, especially a lay person, hears ‘value,’ I think it’s very easy to construe that as cost savings or reducing costs or doing it on the cheap,” he says. Instead, when talking to medical trainees, he likes to define high-value care by quoting Bernard Lown, MD, founder of the Brookline, Mass.-based Lown Institute: “As much as possible for the patient, as little as possible to the patient.”

Perhaps the biggest sign of success in getting that message to stick will come when the flood of cautionary tales becomes a trickle once again.

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Niess MA, Prochazka A. Preoperative chest x-rays: a teachable moment. JAMA Intern Med. 2014;174(1):12.
2. Institute of Medicine (US) Roundtable on Evidence-Based Medicine; Yong PL, Saunders RS, Olsen LA, editors. The healthcare imperative: Lowering costs and improving outcomes: workshop series summary. National Academies Press (US); 2010. Available at: http://www.ncbi.nlm.nih.gov/books/NBK53920/. Accessed May 14, 2015.
3. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299(23):2789-2791.
4. Moriates C, Shah NT, Arora VM. First, do no (financial) harm. JAMA. 2013;310(6):577-578.
5. Moriates C, Mourad M, Novelero M, Wachter RM. Development of a hospital-based program focused on improving healthcare value. J Hosp Med. 2014; 9(10):671-677.
6. Fogerty RL, Heavner JJ, Moriarty JP, Sofair AN, Jenq G. Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE). Teach Learn Med. 2014;26(1):90-94.
7. Larochelle MR, Knight AM, Pantle H, Riedel S, Trost JC. Reducing excess cardiac biomarker testing at an academic medical center. J Gen Intern Med. 2014;29(11):1468-1474.

Three studies, same conclusion. Three separate studies largely agreed that unnecessary care or overtreatment represents the top contributor to wasteful healthcare in the U.S.

1 Main contributors to $600 to $800 billion in annual healthcare waste

40% Unnecessary care (“Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure”)

19% Fraud

17% Administrative inefficiency

12% Healthcare provider errors

6% Preventable conditions

6% Lack of care coordination

Source: Thomson Reuters, 2010

2 Main contributors to $765 billion in annual healthcare waste

27% Unnecessary services

25% Excessive administrative costs

17% Inefficiently delivered services

14% Prices that are too high

10% Fraud

7% Missed prevention opportunities

Source: Institute of Medicine working group, 2011

3 Main contributors to $558 billion (low estimate) - $1263 billion (high estimate) in healthcare waste for 2011

28% (low) or 18% (high) Overtreatment (“Waste that comes from subjecting patients to care that, according to ound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science”)

19% (low) or 31% (high) Administrative complexity

18% (low) or 12% (high) Failures of care delivery

15% (low) or 14% (high) Pricing failures

15% (low) or 22% (high) Fraud and abuse

4% (low) or 4% (high) Failures of care coordination

Source: RAND Corporation, 2012

A fourth study digs into some of the key drivers of overutilization:

1 Physician training and culture

2 Cultural preference for technological solutions

3 Direct-to-consumer marketing

4 Physician-directed pharmaceutical marketing

5 Fee-for-service payment structure

“The reality is that we are all human beings in the end. If I get paid more to do more, even if I don’t think I’m going to do more, I’m going to do more, because getting paid is very influential.”

—Brandon Combs, MD

6 Medical malpractice laws and defensive medicine

“People’s perspective of how likely they are to get sued drives behaviors, whether or not they actually are likely to get sued, and this has been shown many times.”

—Christopher Moriates, MD

7 Lack of cost transparency “It’s not about knowing the exact dollars and cents—that actually doesn’t matter. But it is about having some idea of magnitude, like an MRI is twice as expensive as a CT. When is it worth twice as much? When is it high value?”

—Christopher Moriates, MD

Three studies, same conclusion. Three separate studies largely agreed that unnecessary care or overtreatment represents the top contributor to wasteful healthcare in the U.S.

1 Main contributors to $600 to $800 billion in annual healthcare waste

40% Unnecessary care (“Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure”)

19% Fraud

17% Administrative inefficiency

12% Healthcare provider errors

6% Preventable conditions

6% Lack of care coordination

Source: Thomson Reuters, 2010

2 Main contributors to $765 billion in annual healthcare waste

27% Unnecessary services

25% Excessive administrative costs

17% Inefficiently delivered services

14% Prices that are too high

10% Fraud

7% Missed prevention opportunities

Source: Institute of Medicine working group, 2011

3 Main contributors to $558 billion (low estimate) - $1263 billion (high estimate) in healthcare waste for 2011

28% (low) or 18% (high) Overtreatment (“Waste that comes from subjecting patients to care that, according to ound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science”)

19% (low) or 31% (high) Administrative complexity

18% (low) or 12% (high) Failures of care delivery

15% (low) or 14% (high) Pricing failures

15% (low) or 22% (high) Fraud and abuse

4% (low) or 4% (high) Failures of care coordination

Source: RAND Corporation, 2012

A fourth study digs into some of the key drivers of overutilization:

1 Physician training and culture

2 Cultural preference for technological solutions

3 Direct-to-consumer marketing

4 Physician-directed pharmaceutical marketing

5 Fee-for-service payment structure

“The reality is that we are all human beings in the end. If I get paid more to do more, even if I don’t think I’m going to do more, I’m going to do more, because getting paid is very influential.”

—Brandon Combs, MD

6 Medical malpractice laws and defensive medicine

“People’s perspective of how likely they are to get sued drives behaviors, whether or not they actually are likely to get sued, and this has been shown many times.”

—Christopher Moriates, MD

7 Lack of cost transparency “It’s not about knowing the exact dollars and cents—that actually doesn’t matter. But it is about having some idea of magnitude, like an MRI is twice as expensive as a CT. When is it worth twice as much? When is it high value?”

—Christopher Moriates, MD

Three studies, same conclusion. Three separate studies largely agreed that unnecessary care or overtreatment represents the top contributor to wasteful healthcare in the U.S.

1 Main contributors to $600 to $800 billion in annual healthcare waste

40% Unnecessary care (“Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure”)

19% Fraud

17% Administrative inefficiency

12% Healthcare provider errors

6% Preventable conditions

6% Lack of care coordination

Source: Thomson Reuters, 2010

2 Main contributors to $765 billion in annual healthcare waste

27% Unnecessary services

25% Excessive administrative costs

17% Inefficiently delivered services

14% Prices that are too high

10% Fraud

7% Missed prevention opportunities

Source: Institute of Medicine working group, 2011

3 Main contributors to $558 billion (low estimate) - $1263 billion (high estimate) in healthcare waste for 2011

28% (low) or 18% (high) Overtreatment (“Waste that comes from subjecting patients to care that, according to ound science and the patients’ own preferences, cannot possibly help them—care rooted in outmoded habits, supply-driven behaviors, and ignoring science”)

19% (low) or 31% (high) Administrative complexity

18% (low) or 12% (high) Failures of care delivery

15% (low) or 14% (high) Pricing failures

15% (low) or 22% (high) Fraud and abuse

4% (low) or 4% (high) Failures of care coordination

Source: RAND Corporation, 2012

A fourth study digs into some of the key drivers of overutilization:

1 Physician training and culture

2 Cultural preference for technological solutions

3 Direct-to-consumer marketing

4 Physician-directed pharmaceutical marketing

5 Fee-for-service payment structure

“The reality is that we are all human beings in the end. If I get paid more to do more, even if I don’t think I’m going to do more, I’m going to do more, because getting paid is very influential.”

—Brandon Combs, MD

6 Medical malpractice laws and defensive medicine

“People’s perspective of how likely they are to get sued drives behaviors, whether or not they actually are likely to get sued, and this has been shown many times.”

—Christopher Moriates, MD

7 Lack of cost transparency “It’s not about knowing the exact dollars and cents—that actually doesn’t matter. But it is about having some idea of magnitude, like an MRI is twice as expensive as a CT. When is it worth twice as much? When is it high value?”

—Christopher Moriates, MD

1 Caring Wisely Program

http://healthvalue.ucsf.edu/caring-wisely

• Started in 2012 within the division of hospital medicine at the University of California, San Francisco (UCSF), the program sponsored or collaborated on six high-value care projects within its first year. “We don’t shy away from the fact that part of what we do is address cost, but it is about making sure that we’ve got the right mindset and right frame, which is that we’re going to improve quality while decreasing costs and keeping it really patient centered,” says Christopher Moriates, MD, program director and an assistant clinical professor.
• Beyond its successful Nebs No More After 24 project, Caring Wisely helped hospital pharmacists and the UCSF Medication Outcomes Center develop and implement an evidence-based initiative to cut inappropriate stress ulcer prophylaxis in intensive care unit patients. After its first month, the program had cut unnecessary use of the medication from 19% to 6.6%.

2 Choosing Wisely Program

http://www.choosingwisely.org

• Launched in 2012 as an initiative of the ABIM Foundation and based on a pilot project by the National Physicians Alliance, Choosing Wisely was designed to encourage more proactive conversations between providers and patients. The goal is to help patients choose care that is both evidence-based and necessary, while minimizing harm and avoiding duplication of tests or procedures.
• Since its debut, the program has gathered nearly 60 specialty society lists of “Five Things Physicians and Patients Should Question,” including two lists compiled by SHM for adult and pediatric hospital medicine. As a complement, Consumer Reports and many of the specialty societies have collaborated on 75 patient-friendly reports that dispense advice about whether a test, treatment, or procedure is really needed.

3 Costs of Care

www.costsofcare.org

• Founded in 2009 by Neel Shah, MD, an assistant professor at Harvard Medical School, the nonprofit got its start by collecting stories from patients and physicians about unnecessary or inflated healthcare costs. “It had a manifesto about what the role of physicians ought to be and thinking about healthcare costs, and that message actually really resonated with a lot of people,” Dr. Shah says. “That basic message that we decide what goes on the bill, patients have to pay for it, and yet we don’t know what it’s costing them—that just seemed crazy and we heard from a lot of people, both from patients with whom that message resonated and physicians who were like, ‘Yeah.’”
• In 2010, the organizers hosted their first essay contest and ended up receiving more than 300 entries; several were subsequently included as case reports in a report on healthcare waste by the Institute of Medicine. The nonprofit, supported by the ABIM Foundation and other institutions, has since led to an educational venture called the Teaching Value Project, a textbook titled Understanding Value-Based Care (McGraw-Hill), and a “Costs of Care” iPhone app—all designed to help clinicians make high-value clinical decisions and increase price transparency.

4 The Do No Harm Project

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/

GIM/education/DoNoHarmProject/Pages/Welcome.aspx

• Launched in 2012 at the University of Colorado by Brandon Combs, MD, and Tanner Caverly, MD, MPH, the project is aimed at medical trainees. Starting with the internal medicine program, the physicians asked medical residents to reflect on a patient who had suffered an adverse consequence from medical overuse. “This was reasonable care that was nevertheless unneeded or unwanted by a fully informed patient,” Dr. Combs says. “So this isn’t errors or malpractice; this is the stuff that flies under the radar, the stuff that people might miss.”
• The project uses clinical vignettes written by medical trainees (including those found in the “Teachable Moments” section of JAMA Internal Medicine) to improve the recognition of potential harm from overuse and to spur a culture change. In 2013, the Teaching Value and Choosing Wisely Competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized the project as one of its Innovations award winners; so far, five internal medicine and emergency medicine programs around the country have adopted the model.

5 I-CARE

http://wingofzock.org/2013/12/05/yales-i-care-engages-residents-faculty-on-costs-in-friendly-competition/

• The Interactive Cost-Awareness Resident Exercise (I-CARE) was launched in 2011 by Yale hospitalist Robert Fogerty, MD, MPH, and colleagues. The friendly competition among medical students, interns, residents, and attending physicians uses a traditional morning report structure and charge data. At these conferences, the providers compete to come up with the correct diagnosis using the fewest resources possible. In 2013, the Teaching Value and Choosing Wisely competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized I-CARE as one of its Innovations award winners.
• “Physicians tend not to have a lot of business training,” Dr. Fogerty says. “They don’t have a lot of financial training. They don’t have a lot of economics background, and when you tell them that healthcare expense is 18% of GDP [gross domestic product], they don’t really know what that means. When you tell them that that would be in the top 10 of world economies, now they’re starting to get a picture of it. And when you tell them that that CAT scan you just ordered is going to cost your patient $1,200, that’s an eye-opening number that they can understand. So I think the purpose behind I-CARE was to take this seemingly insurmountable problem and to begin to digest it into small enough bits of information that allowed this problem to be accessible to the trainees.”

6 Providers for Responsible Ordering (PRO)

www.providersforresponsibleordering.org

• The organization launched in 2009 with a mission to “promote high-value care and create a culture that minimizes unnecessary or potentially-harmful diagnostic tests and interventions.” By the end of 2014, five chapters had been established and more than 150 providers had signed the PRO pledge that asks signatories, in part, “to provide my patients with all of the care that they need and none that they do not, thereby protecting them from unnecessary diagnostic tests and treatments.”
• “Our model is simple and yet powerful. It’s a grass-roots effort that any interested provider can join, and it builds on a peer-to-peer approach of establishment of chapters that solve local problems and reporting of those solutions back to the national group,” says Anthony Accurso, MD, PRO faculty director at Johns Hopkins Bayview Medical Center in Baltimore.

1 Caring Wisely Program

http://healthvalue.ucsf.edu/caring-wisely

• Started in 2012 within the division of hospital medicine at the University of California, San Francisco (UCSF), the program sponsored or collaborated on six high-value care projects within its first year. “We don’t shy away from the fact that part of what we do is address cost, but it is about making sure that we’ve got the right mindset and right frame, which is that we’re going to improve quality while decreasing costs and keeping it really patient centered,” says Christopher Moriates, MD, program director and an assistant clinical professor.
• Beyond its successful Nebs No More After 24 project, Caring Wisely helped hospital pharmacists and the UCSF Medication Outcomes Center develop and implement an evidence-based initiative to cut inappropriate stress ulcer prophylaxis in intensive care unit patients. After its first month, the program had cut unnecessary use of the medication from 19% to 6.6%.

2 Choosing Wisely Program

http://www.choosingwisely.org

• Launched in 2012 as an initiative of the ABIM Foundation and based on a pilot project by the National Physicians Alliance, Choosing Wisely was designed to encourage more proactive conversations between providers and patients. The goal is to help patients choose care that is both evidence-based and necessary, while minimizing harm and avoiding duplication of tests or procedures.
• Since its debut, the program has gathered nearly 60 specialty society lists of “Five Things Physicians and Patients Should Question,” including two lists compiled by SHM for adult and pediatric hospital medicine. As a complement, Consumer Reports and many of the specialty societies have collaborated on 75 patient-friendly reports that dispense advice about whether a test, treatment, or procedure is really needed.

3 Costs of Care

www.costsofcare.org

• Founded in 2009 by Neel Shah, MD, an assistant professor at Harvard Medical School, the nonprofit got its start by collecting stories from patients and physicians about unnecessary or inflated healthcare costs. “It had a manifesto about what the role of physicians ought to be and thinking about healthcare costs, and that message actually really resonated with a lot of people,” Dr. Shah says. “That basic message that we decide what goes on the bill, patients have to pay for it, and yet we don’t know what it’s costing them—that just seemed crazy and we heard from a lot of people, both from patients with whom that message resonated and physicians who were like, ‘Yeah.’”
• In 2010, the organizers hosted their first essay contest and ended up receiving more than 300 entries; several were subsequently included as case reports in a report on healthcare waste by the Institute of Medicine. The nonprofit, supported by the ABIM Foundation and other institutions, has since led to an educational venture called the Teaching Value Project, a textbook titled Understanding Value-Based Care (McGraw-Hill), and a “Costs of Care” iPhone app—all designed to help clinicians make high-value clinical decisions and increase price transparency.

4 The Do No Harm Project

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/

GIM/education/DoNoHarmProject/Pages/Welcome.aspx

• Launched in 2012 at the University of Colorado by Brandon Combs, MD, and Tanner Caverly, MD, MPH, the project is aimed at medical trainees. Starting with the internal medicine program, the physicians asked medical residents to reflect on a patient who had suffered an adverse consequence from medical overuse. “This was reasonable care that was nevertheless unneeded or unwanted by a fully informed patient,” Dr. Combs says. “So this isn’t errors or malpractice; this is the stuff that flies under the radar, the stuff that people might miss.”
• The project uses clinical vignettes written by medical trainees (including those found in the “Teachable Moments” section of JAMA Internal Medicine) to improve the recognition of potential harm from overuse and to spur a culture change. In 2013, the Teaching Value and Choosing Wisely Competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized the project as one of its Innovations award winners; so far, five internal medicine and emergency medicine programs around the country have adopted the model.

5 I-CARE

http://wingofzock.org/2013/12/05/yales-i-care-engages-residents-faculty-on-costs-in-friendly-competition/

• The Interactive Cost-Awareness Resident Exercise (I-CARE) was launched in 2011 by Yale hospitalist Robert Fogerty, MD, MPH, and colleagues. The friendly competition among medical students, interns, residents, and attending physicians uses a traditional morning report structure and charge data. At these conferences, the providers compete to come up with the correct diagnosis using the fewest resources possible. In 2013, the Teaching Value and Choosing Wisely competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized I-CARE as one of its Innovations award winners.
• “Physicians tend not to have a lot of business training,” Dr. Fogerty says. “They don’t have a lot of financial training. They don’t have a lot of economics background, and when you tell them that healthcare expense is 18% of GDP [gross domestic product], they don’t really know what that means. When you tell them that that would be in the top 10 of world economies, now they’re starting to get a picture of it. And when you tell them that that CAT scan you just ordered is going to cost your patient $1,200, that’s an eye-opening number that they can understand. So I think the purpose behind I-CARE was to take this seemingly insurmountable problem and to begin to digest it into small enough bits of information that allowed this problem to be accessible to the trainees.”

6 Providers for Responsible Ordering (PRO)

www.providersforresponsibleordering.org

• The organization launched in 2009 with a mission to “promote high-value care and create a culture that minimizes unnecessary or potentially-harmful diagnostic tests and interventions.” By the end of 2014, five chapters had been established and more than 150 providers had signed the PRO pledge that asks signatories, in part, “to provide my patients with all of the care that they need and none that they do not, thereby protecting them from unnecessary diagnostic tests and treatments.”
• “Our model is simple and yet powerful. It’s a grass-roots effort that any interested provider can join, and it builds on a peer-to-peer approach of establishment of chapters that solve local problems and reporting of those solutions back to the national group,” says Anthony Accurso, MD, PRO faculty director at Johns Hopkins Bayview Medical Center in Baltimore.

1 Caring Wisely Program

http://healthvalue.ucsf.edu/caring-wisely

• Started in 2012 within the division of hospital medicine at the University of California, San Francisco (UCSF), the program sponsored or collaborated on six high-value care projects within its first year. “We don’t shy away from the fact that part of what we do is address cost, but it is about making sure that we’ve got the right mindset and right frame, which is that we’re going to improve quality while decreasing costs and keeping it really patient centered,” says Christopher Moriates, MD, program director and an assistant clinical professor.
• Beyond its successful Nebs No More After 24 project, Caring Wisely helped hospital pharmacists and the UCSF Medication Outcomes Center develop and implement an evidence-based initiative to cut inappropriate stress ulcer prophylaxis in intensive care unit patients. After its first month, the program had cut unnecessary use of the medication from 19% to 6.6%.

2 Choosing Wisely Program

http://www.choosingwisely.org

• Launched in 2012 as an initiative of the ABIM Foundation and based on a pilot project by the National Physicians Alliance, Choosing Wisely was designed to encourage more proactive conversations between providers and patients. The goal is to help patients choose care that is both evidence-based and necessary, while minimizing harm and avoiding duplication of tests or procedures.
• Since its debut, the program has gathered nearly 60 specialty society lists of “Five Things Physicians and Patients Should Question,” including two lists compiled by SHM for adult and pediatric hospital medicine. As a complement, Consumer Reports and many of the specialty societies have collaborated on 75 patient-friendly reports that dispense advice about whether a test, treatment, or procedure is really needed.

3 Costs of Care

www.costsofcare.org

• Founded in 2009 by Neel Shah, MD, an assistant professor at Harvard Medical School, the nonprofit got its start by collecting stories from patients and physicians about unnecessary or inflated healthcare costs. “It had a manifesto about what the role of physicians ought to be and thinking about healthcare costs, and that message actually really resonated with a lot of people,” Dr. Shah says. “That basic message that we decide what goes on the bill, patients have to pay for it, and yet we don’t know what it’s costing them—that just seemed crazy and we heard from a lot of people, both from patients with whom that message resonated and physicians who were like, ‘Yeah.’”
• In 2010, the organizers hosted their first essay contest and ended up receiving more than 300 entries; several were subsequently included as case reports in a report on healthcare waste by the Institute of Medicine. The nonprofit, supported by the ABIM Foundation and other institutions, has since led to an educational venture called the Teaching Value Project, a textbook titled Understanding Value-Based Care (McGraw-Hill), and a “Costs of Care” iPhone app—all designed to help clinicians make high-value clinical decisions and increase price transparency.

4 The Do No Harm Project

http://www.ucdenver.edu/academics/colleges/medicalschool/departments/medicine/

GIM/education/DoNoHarmProject/Pages/Welcome.aspx

• Launched in 2012 at the University of Colorado by Brandon Combs, MD, and Tanner Caverly, MD, MPH, the project is aimed at medical trainees. Starting with the internal medicine program, the physicians asked medical residents to reflect on a patient who had suffered an adverse consequence from medical overuse. “This was reasonable care that was nevertheless unneeded or unwanted by a fully informed patient,” Dr. Combs says. “So this isn’t errors or malpractice; this is the stuff that flies under the radar, the stuff that people might miss.”
• The project uses clinical vignettes written by medical trainees (including those found in the “Teachable Moments” section of JAMA Internal Medicine) to improve the recognition of potential harm from overuse and to spur a culture change. In 2013, the Teaching Value and Choosing Wisely Competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized the project as one of its Innovations award winners; so far, five internal medicine and emergency medicine programs around the country have adopted the model.

5 I-CARE

http://wingofzock.org/2013/12/05/yales-i-care-engages-residents-faculty-on-costs-in-friendly-competition/

• The Interactive Cost-Awareness Resident Exercise (I-CARE) was launched in 2011 by Yale hospitalist Robert Fogerty, MD, MPH, and colleagues. The friendly competition among medical students, interns, residents, and attending physicians uses a traditional morning report structure and charge data. At these conferences, the providers compete to come up with the correct diagnosis using the fewest resources possible. In 2013, the Teaching Value and Choosing Wisely competition, jointly sponsored by Costs of Care and the ABIM Foundation, recognized I-CARE as one of its Innovations award winners.
• “Physicians tend not to have a lot of business training,” Dr. Fogerty says. “They don’t have a lot of financial training. They don’t have a lot of economics background, and when you tell them that healthcare expense is 18% of GDP [gross domestic product], they don’t really know what that means. When you tell them that that would be in the top 10 of world economies, now they’re starting to get a picture of it. And when you tell them that that CAT scan you just ordered is going to cost your patient $1,200, that’s an eye-opening number that they can understand. So I think the purpose behind I-CARE was to take this seemingly insurmountable problem and to begin to digest it into small enough bits of information that allowed this problem to be accessible to the trainees.”

6 Providers for Responsible Ordering (PRO)

www.providersforresponsibleordering.org

• The organization launched in 2009 with a mission to “promote high-value care and create a culture that minimizes unnecessary or potentially-harmful diagnostic tests and interventions.” By the end of 2014, five chapters had been established and more than 150 providers had signed the PRO pledge that asks signatories, in part, “to provide my patients with all of the care that they need and none that they do not, thereby protecting them from unnecessary diagnostic tests and treatments.”
• “Our model is simple and yet powerful. It’s a grass-roots effort that any interested provider can join, and it builds on a peer-to-peer approach of establishment of chapters that solve local problems and reporting of those solutions back to the national group,” says Anthony Accurso, MD, PRO faculty director at Johns Hopkins Bayview Medical Center in Baltimore.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

The Dartmouth Institute for Health Policy and Clinical Practice and other institutions have long tried to quantify the prevalence and geographic variation of low-value care. Researchers have roughly defined low-value care as tests and procedures for which the potential benefit does not outweigh the potential harm, though the calculus can change significantly from patient to patient.

William Schpero, a former health policy fellow at the Dartmouth Institute and now a PhD student in health policy and management at Yale University, says he and colleagues initially identified three theoretical reasons for the geographical variation. An increase in the use of low-value care, they reasoned, might be driven by patients demanding more intensive treatments, by financial incentives to providers, or by providers supplying more services.

After adjusting for differences in the health status of patient populations, however, the Dartmouth Institute’s work consistently revealed large unexplained geographical variations, a finding that also held true for patients in the last six months of life. These variations, Schpero says, suggest that patient demand is not a major driver. A collaborative Dartmouth and Harvard study, released by the National Bureau of Economic Research in 2013, instead pointed to a more likely rationale, at least during the last two years of a patient’s life.

By linking patient and physician surveys to Medicare claims data, the report examined how physician and patient preferences affected overall healthcare spending in different geographic regions. The paper identified “cowboys,” or physicians who used treatments that were more intensive than those recommended by guidelines, and “comforters,” or physicians who recommended more low-cost treatment protocols.

Older physicians and smaller practices, the study suggested, were more likely to recommend higher levels of follow-up care and fall into the “cowboys” category.

It was this difference in physician culture and beliefs about effective treatment, not patient preferences, that drove most of the variation in healthcare spending. Monetary incentives, meanwhile, had only a marginal effect. If all physicians were to follow professional guidelines for effective care and not exceed recommended treatments, the report suggested, Medicare spending for end-of-life care could be reduced by 36 percent, “which is a huge, huge number,” Schpero says.

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Sometimes, simply knowing what a test costs can make all the difference.

Many physicians have sheepishly admitted that they know little about the price tags attached to the procedures and tests they order on a routine basis—or how that might impact their patients financially. In Medscape’s Physician Compensation Report for 2012, only 38% of surveyed doctors said they regularly discussed the cost of treatment with their patients. The following year, the rate had dropped to 30%.

One medical resident, Neel Shah, MD, MPP discovered how important those discussions can be.

After a woman admitted to the ED tested positive on a pregnancy test, a follow-up hormone test warned of potential trouble with her pregnancy, and Dr. Shah asked her to return to the hospital for an ultrasound.

“She refused to come in until I could tell her how much the ultrasound would cost,” he recalls. Other providers had told him that bringing up costs with patients would decrease their trust, because they didn’t want doctors to focus on anything but providing care. “With her, it was very clear that my inability to tell her what things cost actually eroded her trust in me and, in her mind, she was being reasonable,” he says.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends.”

–Neel Shah, MD, MPP

Dr. Shah had already grown disillusioned in medical school, watching providers around him make clinical decisions without regard to the cost for patients, and he took a hiatus to study politics at Harvard’s Kennedy School of Government. When he and a collaborator subsequently launched the nonprofit organization Costs of Care to point out the downsides of that lack of transparency, however, they received a less-than-enthusiastic reception from some quarters.

“If you’re trying to tell doctors or clinicians in general that we ought to be doing things differently, as a young person, it’s not a great way to make friends,” says

Dr. Shah, who is now an assistant professor at Harvard Medical School in Boston.

The group gained traction as its cost-awareness manifesto began to resonate with the public, however, and the essays on its site have been picked up by multiple media groups. Dr. Shah’s own experience with his pregnant patient, however, made one of the strongest impressions on him.

Getting an answer to her about the cost of an ultrasound took nearly 24 hours, he recalls, “because nobody around me knew.” In the interim, he fretted that his patient might have an ectopic pregnancy and bleed to death. She didn’t, but the outcome could have been very different, he says.

“That really struck home for me, for sure,” he adds. “I think about that all the time.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”

Reform advocates agree that a doctor’s time is a scarce resource that can contribute to waste when it is stretched too thin.

“It’s not just about overtreatment; it’s about getting the right treatment, and the right treatment depends on the right diagnosis, and the right diagnosis depends on really taking the time to think carefully with the patient about what’s going on,” says Vineet Arora, MD, MAPP, FHM, a hospitalist and researcher at the University of Chicago. A doctor “pulled in 10 different ways in the hospital” simply may not have the bandwidth to devote sufficient time to a complex patient; ordering a test can then seem like an enticing way to save some time.

Although electronic health records may have simplified the process for ordering CT scans and other tests, Dr. Arora says, they sometimes supersede important conversations that should take place with radiologists or other specialists about whether those tests are truly necessary. Meanwhile, providers face a proliferation of reporting duties. Recent surveys, in fact, suggest that doctors are “drowning” in paperwork and computer-based reporting requirements. Placing additional demands on a doctor’s time, Dr. Arora says, can limit his or her availability for other duties.

With hospitalists caring for increasingly complex patients with more complicated therapeutics, UCSF’s Christopher Moriates, MD, agrees that insufficient time can be an important barrier to change. It is not, however, insurmountable. If the ethos of medicine is “First, do no harm,” he says, it’s critical for doctors to remember that waste is harm.

“If we’re really going to stand by that,” he says, “then it rises to be something that we really need to take on.”