Practicing cost-conscious medicine

The Journal of Healthcare Contracting recently interviewed Steven Weinberger, M.D., executive vice president and CEO of the American College of Physicians, regarding the unsustainable cost of care. The following is an excerpt. For the full article, download the digital issue of JHC here

The need to improve quality of care and to ensure patient safety are key issues facing the medical profession today. But there’s a new elephant in the room, which may be just as critical to acknowledge: the unsustainable cost of care.

Writing in the Annals of Internal Medicine (Sept. 20, 2011), Steven Weinberger, M.D., executive vice president and CEO of the American College of Physicians, calls for medical schools to teach residents the need for stewardship of resources and practicing in a cost-conscious fashion. “It is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of healthcare costs,” he writes.

Specifically, Weinberger is calling for a new “general competency” for medical residents, which would call for residents “to understand the need for stewardship of resources and practice cost-conscious care, including avoiding the overuse and misuse of diagnostic tests and therapies that do not benefit patient care but add to healthcare costs.

The proposed competency would be the seventh competency for medical residents. The existing six were defined 10 years ago by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties. They are:

• Medical knowledge. Resident should demonstrate knowledge of established and evolving biomedical, clinical, epidemiologic and social-behavioral sciences, as well as the application of this knowledge in patient care.
• Patient care. The resident should be able to provide patient care that is compassionate, appropriate and effective for the treatment of health problems and the promotion of health.
• Professionalism. The resident should demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
• Interpersonal and communication skills. The resident should demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families and health professionals.
• Practice-based learning and improvement. The resident should demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning.
• Systems-based practice. The resident should demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

 

Recently, the Journal of Healthcare Contracting submitted several questions to Weinberger. Here are those questions, and Weinberger’s responses.

The Journal of Healthcare Contracting: Why have you chosen the year 2011 to suggest a general competency in cost-conscious care and stewardship of resources? What would have happened had you suggested this, say, 10 years ago? Five years ago? 

Steven Weinberger: This time is particularly critical, given the federal debt problem that is driven in large part by the ever-escalating costs of healthcare. Suggesting this five or 10 years ago probably would have gotten some interest, but nowhere near the type of interest and traction that it is getting now.

JHC: Why do you say in the Annals article that past efforts to teach residents about cost-effective care have not been particularly effective? What have been the shortcomings, and how can they be overcome? 

Weinberger: Past studies that have looked at the issue have shown transient rather than long-lasting benefit. I think the main problem is that there needs to be a real change in the culture of the training environment, much of which needs to be driven by the faculty. The faculty are important not only because of what they teach and what they stress to trainees, but also because of the role model they set in their own care of patients.

JHC: In the Annals article, you make the point that the question most often posed on teaching rounds is, “Why didn’t you order test X?” rather than “Why did you order test X and what are you going to do with the information?” How do you “train the trainers” to teach cost-conscious care and stewardship of resources? How quickly can this change of culture in today’s medical schools be implemented? 

Weinberger: I think that the early trainers will need to learn alongside the trainees. We’ll need some educational materials and standards to come out nationally (e.g., from the American College of Physicians and other organizations), supported, hopefully, by a few “champions” at each institution who want to effect change. I suspect this type of change will take a couple of years.

JHC: What would this training look like?  

Weinberger: The training is partly didactic – probably done through case-based studies – and is partly in the course of patient care, through the types of discussions and teaching that go on every day in teaching institutions as part of routine patient care.

 Read the rest of the article, A Teachable Moment, here