Series Introduction: Doing the right thing to control health care costs

Health care costs in the United States are rising at an unsustainable rate, currently approaching 20% of the nation’s gross domestic product.¹ The reasons for the rapidly increasing costs are many and complex and include new devices and drugs, greater intensity of care in the last years of life, and most perniciously, wasted care.

See related article

In its 2010 report The Healthcare Imperative: Lowering costs and Improving Outcomes, the Institute of Medicine estimated that we spend $765 billion annually on wasted care, defined as care that provides no value to the patient.² Identified causes of wasted care include inefficiently delivered services, excessive pricing, and missed opportunities for prevention. Unnecessary services provided by physicians account for $210 billion annually, accounting for 30% of “wasted care.” Chief culprits are unnecessary imaging procedures and diagnostic tests. These two categories of physician-provided services have skyrocketed, with a cumulative increase of approximately 90% from 2000 to 2009.³

Despite our extensive use of diagnostic imaging and other testing, the US population does not benefit from better health or longer life than other industrialized nations. For example, US male life expectancy from birth is the lowest of 21 high-income countries despite greater use of health care resources, such as an 84% higher rate of magnetic resonance imaging testing per 1,000 population.⁴

These costs are generated directly by physicians. As aptly put by Walt Kelly’s cartoon character Pogo, “We have met the enemy, and he is us.”

COST AND VALUE

This economic crisis is not all about cost, but about value. The distinction between cost and value is important and provides a framework for physicians striving to be good shepherds of health care resources.

An expensive imaging procedure or diagnostic test may be a good value if its net benefit outweighs or at least justifies the cost. A computed tomographic angiogram provides good value for patients with an intermediate probability of pulmonary embolism in its ability to identify those who may benefit from potentially life-saving therapy.

Conversely, inexpensive tests may provide little value if they provide no patient benefit or even lead to downstream harm such as unnecessary additional testing or therapy. An example might be preoperative electrocardiography in a patient at low risk and without symptoms. Not uncommonly, unexpected electrocardiographic abnormalities are pursued with additional diagnostic tests, even though there is no evidence that patients without symptoms and at low risk benefit from this additional diagnostic scrutiny.

Because some high-cost interventions provide benefit and low-cost interventions may not, efforts to control cost should focus on value, not just cost.

REASONS FOR EXCESSIVE TESTING

Many reasons are offered for excessive testing, including assuaging concerns about diagnostic uncertainty, lack of confidence in diagnostic skills, meeting patient expectations, and lack of time to educate patients about the appropriate use of imaging and diagnostic testing.⁵ Both attending physicians and residents have knowledge gaps that contribute to overuse of testing.⁶ Physicians also report deliberate overtesting in a misguided attempt to prevent malpractice claims,⁵ an unproven defensive strategy that may be associated with more harm than benefit.

EDUCATIONAL INITIATIVES TO CONTROL COSTS

To meet this growing need for clinical guidance and education, regulatory agencies, professional societies, consumer groups, and foundations have prioritized high-value care as an important strategic objective. For example, cost-effective care has been incorporated into the training milestones reported to the Accreditation Council for Graduate Medical Education by internal medicine residency programs. The American College of Physicians (ACP) and the Alliance of Academic Internal Medicine have developed a curriculum to teach high-value care to internal medicine residents, and the ACP has released an interactive online curriculum for practicing physicians. The American Board of Internal Medicine Foundation launched its Choosing Wisely campaign, which asks professional societies to create lists of “things physicians and patients should question” to help make wise decisions about appropriate care. Consumer Reports has joined both the ACP and the American Board of Internal Medicine Foundation to promote high-value care to its consumer audience.

‘SMART TESTING’: THE JOURNAL’S CONTRIBUTION TO CONTROLLING COST

In this issue, Cleveland Clinic Journal of Medicine initiates its contribution to high-value care with a new series—“Smart Testing.”⁷ The series offers short, clinically engaging vignettes and discussions on the appropriate use of imaging procedures and other diagnostic tests. The vignettes depict common situations in clinical practice, and the discussions focus on identifying and incorporating evidence-based recommendations most likely to provide optimal patient outcome and value. This laudable goal of the Journal is reminiscent of the exhortation by Samuel Clemens (Mark Twain): “Always do right. This will gratify some people and astonish the rest.”

Physicians want to do the right thing, and with the help of the Journal, we can gratify ourselves and society with our efforts to deliver high-value care.

Health care costs in the United States are rising at an unsustainable rate, currently approaching 20% of the nation’s gross domestic product.¹ The reasons for the rapidly increasing costs are many and complex and include new devices and drugs, greater intensity of care in the last years of life, and most perniciously, wasted care.

See related article

In its 2010 report The Healthcare Imperative: Lowering costs and Improving Outcomes, the Institute of Medicine estimated that we spend $765 billion annually on wasted care, defined as care that provides no value to the patient.² Identified causes of wasted care include inefficiently delivered services, excessive pricing, and missed opportunities for prevention. Unnecessary services provided by physicians account for $210 billion annually, accounting for 30% of “wasted care.” Chief culprits are unnecessary imaging procedures and diagnostic tests. These two categories of physician-provided services have skyrocketed, with a cumulative increase of approximately 90% from 2000 to 2009.³

Despite our extensive use of diagnostic imaging and other testing, the US population does not benefit from better health or longer life than other industrialized nations. For example, US male life expectancy from birth is the lowest of 21 high-income countries despite greater use of health care resources, such as an 84% higher rate of magnetic resonance imaging testing per 1,000 population.⁴

These costs are generated directly by physicians. As aptly put by Walt Kelly’s cartoon character Pogo, “We have met the enemy, and he is us.”

COST AND VALUE

This economic crisis is not all about cost, but about value. The distinction between cost and value is important and provides a framework for physicians striving to be good shepherds of health care resources.

An expensive imaging procedure or diagnostic test may be a good value if its net benefit outweighs or at least justifies the cost. A computed tomographic angiogram provides good value for patients with an intermediate probability of pulmonary embolism in its ability to identify those who may benefit from potentially life-saving therapy.

Conversely, inexpensive tests may provide little value if they provide no patient benefit or even lead to downstream harm such as unnecessary additional testing or therapy. An example might be preoperative electrocardiography in a patient at low risk and without symptoms. Not uncommonly, unexpected electrocardiographic abnormalities are pursued with additional diagnostic tests, even though there is no evidence that patients without symptoms and at low risk benefit from this additional diagnostic scrutiny.

Because some high-cost interventions provide benefit and low-cost interventions may not, efforts to control cost should focus on value, not just cost.

REASONS FOR EXCESSIVE TESTING

Many reasons are offered for excessive testing, including assuaging concerns about diagnostic uncertainty, lack of confidence in diagnostic skills, meeting patient expectations, and lack of time to educate patients about the appropriate use of imaging and diagnostic testing.⁵ Both attending physicians and residents have knowledge gaps that contribute to overuse of testing.⁶ Physicians also report deliberate overtesting in a misguided attempt to prevent malpractice claims,⁵ an unproven defensive strategy that may be associated with more harm than benefit.

EDUCATIONAL INITIATIVES TO CONTROL COSTS

To meet this growing need for clinical guidance and education, regulatory agencies, professional societies, consumer groups, and foundations have prioritized high-value care as an important strategic objective. For example, cost-effective care has been incorporated into the training milestones reported to the Accreditation Council for Graduate Medical Education by internal medicine residency programs. The American College of Physicians (ACP) and the Alliance of Academic Internal Medicine have developed a curriculum to teach high-value care to internal medicine residents, and the ACP has released an interactive online curriculum for practicing physicians. The American Board of Internal Medicine Foundation launched its Choosing Wisely campaign, which asks professional societies to create lists of “things physicians and patients should question” to help make wise decisions about appropriate care. Consumer Reports has joined both the ACP and the American Board of Internal Medicine Foundation to promote high-value care to its consumer audience.

‘SMART TESTING’: THE JOURNAL’S CONTRIBUTION TO CONTROLLING COST

In this issue, Cleveland Clinic Journal of Medicine initiates its contribution to high-value care with a new series—“Smart Testing.”⁷ The series offers short, clinically engaging vignettes and discussions on the appropriate use of imaging procedures and other diagnostic tests. The vignettes depict common situations in clinical practice, and the discussions focus on identifying and incorporating evidence-based recommendations most likely to provide optimal patient outcome and value. This laudable goal of the Journal is reminiscent of the exhortation by Samuel Clemens (Mark Twain): “Always do right. This will gratify some people and astonish the rest.”

Physicians want to do the right thing, and with the help of the Journal, we can gratify ourselves and society with our efforts to deliver high-value care.

Health care costs in the United States are rising at an unsustainable rate, currently approaching 20% of the nation’s gross domestic product.¹ The reasons for the rapidly increasing costs are many and complex and include new devices and drugs, greater intensity of care in the last years of life, and most perniciously, wasted care.

See related article

In its 2010 report The Healthcare Imperative: Lowering costs and Improving Outcomes, the Institute of Medicine estimated that we spend $765 billion annually on wasted care, defined as care that provides no value to the patient.² Identified causes of wasted care include inefficiently delivered services, excessive pricing, and missed opportunities for prevention. Unnecessary services provided by physicians account for $210 billion annually, accounting for 30% of “wasted care.” Chief culprits are unnecessary imaging procedures and diagnostic tests. These two categories of physician-provided services have skyrocketed, with a cumulative increase of approximately 90% from 2000 to 2009.³

Despite our extensive use of diagnostic imaging and other testing, the US population does not benefit from better health or longer life than other industrialized nations. For example, US male life expectancy from birth is the lowest of 21 high-income countries despite greater use of health care resources, such as an 84% higher rate of magnetic resonance imaging testing per 1,000 population.⁴

These costs are generated directly by physicians. As aptly put by Walt Kelly’s cartoon character Pogo, “We have met the enemy, and he is us.”

COST AND VALUE

This economic crisis is not all about cost, but about value. The distinction between cost and value is important and provides a framework for physicians striving to be good shepherds of health care resources.

An expensive imaging procedure or diagnostic test may be a good value if its net benefit outweighs or at least justifies the cost. A computed tomographic angiogram provides good value for patients with an intermediate probability of pulmonary embolism in its ability to identify those who may benefit from potentially life-saving therapy.

Conversely, inexpensive tests may provide little value if they provide no patient benefit or even lead to downstream harm such as unnecessary additional testing or therapy. An example might be preoperative electrocardiography in a patient at low risk and without symptoms. Not uncommonly, unexpected electrocardiographic abnormalities are pursued with additional diagnostic tests, even though there is no evidence that patients without symptoms and at low risk benefit from this additional diagnostic scrutiny.

Because some high-cost interventions provide benefit and low-cost interventions may not, efforts to control cost should focus on value, not just cost.

REASONS FOR EXCESSIVE TESTING

Many reasons are offered for excessive testing, including assuaging concerns about diagnostic uncertainty, lack of confidence in diagnostic skills, meeting patient expectations, and lack of time to educate patients about the appropriate use of imaging and diagnostic testing.⁵ Both attending physicians and residents have knowledge gaps that contribute to overuse of testing.⁶ Physicians also report deliberate overtesting in a misguided attempt to prevent malpractice claims,⁵ an unproven defensive strategy that may be associated with more harm than benefit.

EDUCATIONAL INITIATIVES TO CONTROL COSTS

To meet this growing need for clinical guidance and education, regulatory agencies, professional societies, consumer groups, and foundations have prioritized high-value care as an important strategic objective. For example, cost-effective care has been incorporated into the training milestones reported to the Accreditation Council for Graduate Medical Education by internal medicine residency programs. The American College of Physicians (ACP) and the Alliance of Academic Internal Medicine have developed a curriculum to teach high-value care to internal medicine residents, and the ACP has released an interactive online curriculum for practicing physicians. The American Board of Internal Medicine Foundation launched its Choosing Wisely campaign, which asks professional societies to create lists of “things physicians and patients should question” to help make wise decisions about appropriate care. Consumer Reports has joined both the ACP and the American Board of Internal Medicine Foundation to promote high-value care to its consumer audience.

‘SMART TESTING’: THE JOURNAL’S CONTRIBUTION TO CONTROLLING COST

In this issue, Cleveland Clinic Journal of Medicine initiates its contribution to high-value care with a new series—“Smart Testing.”⁷ The series offers short, clinically engaging vignettes and discussions on the appropriate use of imaging procedures and other diagnostic tests. The vignettes depict common situations in clinical practice, and the discussions focus on identifying and incorporating evidence-based recommendations most likely to provide optimal patient outcome and value. This laudable goal of the Journal is reminiscent of the exhortation by Samuel Clemens (Mark Twain): “Always do right. This will gratify some people and astonish the rest.”

Physicians want to do the right thing, and with the help of the Journal, we can gratify ourselves and society with our efforts to deliver high-value care.