In invited commentary, Dr. Franklin A. Michota said

that “Dr. Leonard Feldman and his colleagues at Johns Hopkins

Hospital have recently

demonstrated that cost visibility for health care providers can decrease

resource utilization. They are cautious to limit their findings to several

specific laboratory tests; however, this simple approach has widespread

applicability beyond laboratory testing and has the potential for great cost

savings across the U.S.

health care system. But before we start putting visible price tags on all of

our hospital order sheets, products, and medications, we should review what we

really know about cost visibility and the risk for adverse consequences”

according to Dr. Michota, director of academic affairs in the department of

hospital medicine at the Cleveland Clinic.

“Dr. Feldman readily

admits that patient outcomes were not reviewed in their preliminary study. It

certainly seems plausible that cost visibility reduced the ordering of

redundant and unnecessary laboratory tests. It is also plausible that necessary

and appropriate testing was omitted because of concerns over cost. We cannot

and should not look at a reduction in resource utilization with a smile on our

face without confirming at least a neutral effect on patient outcome” said Dr.

Michota.

“To that end, we must

also consider the spectrum of patient outcome and how we as individual

providers factor cost into medical decision making. There are many outcomes in

patient care, including patient satisfaction and comfort. Which outcomes should

matter the most? From which perspective do we apply our cost thresholds?

“I have often said

that I have yet to meet an American who isn’t willing to have an infinite

amount of money spent on them for the smallest improvement in outcome. How

should physicians weigh the various outcomes in balance with the visible cost?

One particular danger is the effect of physician experience on the benefit/cost

equation. Cost visibility puts the cost data right in front of the physician in

real time, yet there is no ‘equal display’ regarding the benefits. It stands to

reason that if the physician is unaware of the benefits due to lack of

experience, the medical decision making will be inappropriately weighted toward

the cost,” Dr. Michota said.

“Finally, there is

also an inherent injustice to applying cost-based decisions at the individual

patient level which is the basis of the cost-visibility approach. Most patients

are randomly assigned to hospitalists. Despite identical presentations, one

patient could receive less ‘care’ (such as testing, therapies, resources) because

his or her physician weighted the visible cost of care differently than did the

physician caring for the patient in the next bed. To avoid this conflict,

bioethicists recommend that cost-based decisions be made at the population, not

the individual level. Hospital formularies are a good example of this

technique. Cost visibility applied to individual patients without standardized

approaches on how to use the information consistently across all patients could

otherwise be considered unethical,” he said.

“Ultimately,

hospitalists should strive for value (quality/cost) in health care. As patient

advocates, we need to make sure that the quality is just as visible as the

cost,” according to Dr. Michota.

Dr. Franklin A. Michota, director of academic affairs in the department of

hospital medicine at the Cleveland Clinic. He declared no relevant financial disclosures.