Balancing the Value Equation Teaching and Assessing Cost

Balancing the Value Equation: Teaching and Assessing Cost Effective Care

Workshop Goals • Prepare faculty involved in resident education to more effectively practice and teach principles of high-value cost-conscious care (HVCCC) and assess residents’ ability to provide HVCCC • Develop ongoing collaboration between regional institutions in the area of HVCCC

Workshop Objectives • Define HVCCC and appreciate its importance • Identify and understand basic principles of HVCCC • Recognize resources available to learn about and teach HVCCC • Apply principles of HVCCC to your patient care • More effectively teach principles of HVCCC • Assess residents’ competency in providing HVCCC using an assessment tool based on milestones • Share ideas with colleagues regarding teaching and evaluation of HVCCC • Describe potential methods of measuring the impact of an assessment tool

Introduction Outline • • • The value equation Why should we care? Review ACP’s High Value Care curriculum Review Choosing Wisely campaign Review barriers to high value care

The Value Equation Benefit Value = Cost

Low cost High cost No improved outcome Improved outcome Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum

Low cost No improved outcome Improved outcome • Daily labs • Annual pap smears • Preoperative CXR in asx patients • CHF peptide (BNP) • • • Vaccinations Pap smear ASA in CAD Diabetes education Good history & physical High cost • MRI for non-specific LBP • Coronary angiography in pts with stable chronic angina • Sinus CT • CT/MRI for simple syncope with normal neuro eval • Anti-retroviral therapy for HIV • ICD placement when meets criteria Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum

Ann Intern Med, 2012

Why should we care? • • • Health system need Public & physician perceptions skewed ACGME Next Accreditation System Residents currently get little or no training Within the current healthcare system, no real disincentive to curb providers’ ordering practices

Health System Need Healthcare costs in the United States are increasing at an unsustainable rate: • $253 billion in 1980 • $714 billion in 1990 • $2. 6 trillion in 2010 Boston: Health Reform Program, Boston University School of Public Health; 2005

Approximately 30% of Healthcare Costs are Wasted Care • $250 -325 billion/year in “unwarranted use” • $75 -100 billion/year in “provider inefficiency and errors” • $25 -50 billion/year in “lack of care coordination” Thomas Reuters, October, 2009

We are ordering more tests… tests imaging Uwe E. Reinhardt blog, NY Times, 12/24/2010.

Physicians are responsible for 87% of wasteful spending Boston: Health Reform Program, Boston University School of Public Health; 2005

Public Perception

Views of US Physicians About Controlling Health Care Costs, JAMA 2013 • 2556 physicians responded to the survey • Who has a “major responsibility” for reducing health care costs? – – – trial lawyers (60%) insurance companies (59%) hospitals and health systems (56%) pharmaceutical and device manufacturers (56%) patients (52%) practicing physicians (36%) • CONCLUSION: “US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models. ”

ACGME Milestone Project

2011 AAMC Graduate Questionnaire • 63. 8% of students reported inadequate instruction on health economics • 45. 9% of students reported inadequate instruction on managed care

• High Value Care Curriculum – Jointly developed by the ACP and AAIM – Developed in an effort to address the “critical seventh general competency for physicians” http: //hvc. acponline. org/

• High Value Care Curriculum – Initially released in July of 2012 – Newest version released Sept 2013 • can be completed in 6 hours • includes more multimedia content • toolbox to help faculty and program directors measure curricular impact and individual resident performance in high value care http: //hvc. acponline. org/

ACP's High Value Care (HVC) initiative connects two important priorities: 1. Helping physicians to provide the best possible care to their patients. 2. Simultaneously reducing unnecessary costs to the healthcare system. http: //hvc. acponline. org/

Six Curriculum Topics 1. Eliminating Healthcare Waste and Overordering of Tests 2. Healthcare Costs and Payment Models 3. Utilizing Biostatistics in Diagnosis, Screening and Prevention 4. High Value Medication Prescribing 5. Overcoming Barriers to High Value Care 6. High Value Quality Improvement

Steps Toward High Value, Cost-Conscious Care 4 • Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering • Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful • Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data) • Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns • Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste

http: //hvc. acponline. org/curriculum_list. html

• Recommendations from more than 50 societies • 30+ societies will announce lists in the next 6 months • Evidence-based recommendations • Consumer Reports is developing and disseminating materials for patients to help patients engage their physicians

http: //www. choosingwisely. org/

What are the potential barriers to high value use of diagnostic tests?

What are the potential barriers to high value use of diagnostic tests? • Lack of guidelines • Poor familiarity with guidelines • Lack of knowledge of costs, including the impact of setting on cost • Defensive medicine (i. e. fear of litigation) • Time pressure (emphasis on shorter LOS and productivity) • Explaining to patients why tests/treatments are not indicated • Takes time • Discomfort with diagnostic uncertainty • Local standards of care • Misaligned financial incentives • Lack of appreciation of harms • Patient expectations • Lack of centrally available information on prior tests http: //hvc. acponline. org

References 1. Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163. 2. ACP, ACP’s High-Value Cost-Conscious Care Curriculum. http: //hvc. acponline. org/curriculum_list. html 3. Uwe E. Reinhardt blog, NY Times, 12/24/2010. 4. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000 -2005. Boston: Health Reform Program, Boston University School of Public Health; 2005. 5. Thomas Reuters. Where can $700 billion in waste be cut annually from the U. S Health Care system? October, 2009. 6. Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program“; 2012. 7. Adapted from Owens, D. Ann Intern Med. 2011; 154: 174 -180 8. ABIM Foundation, Choosing Wisely Campaign. www. choosingwisely. org 9. Qaseem, A. Appropriate Use of Screening and Diagnostic Tests to Foster High-Value, Cost-Conscious Care. Ann Intern Med. 2012; 156: 147 -149 10. Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, 2000 -2005. Boston: Health Reform Program, Boston University School of Public Health; 2005. 11. Thomas Reuters. Where can $700 billion in waste be cut annually from the U. S Health Care system? October, 2009. 12. Dine, et al. Less is More: Developing Your Faculty to Implement the High Value Cost-Conscious Care Curriculum. (video) 12. Association of American Medical Colleges. Medical School Graduate Questionnaire: All Schools Summary Report. Online. https: //www. aamc. org

Commit to Change

Large Group Discussion

Teaching Mindfulness: Small group exercise

Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163.

“Being Mindful” 5 Steps Step 1: Did the patient have this test previously? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163.

Step 1 Examples • Transfer from an outside hospital/clinic – Labs/imaging done just prior to transfer • Blood cultures, x-ray, CT, CBC, CMP, etc • Old records – TSH, A 1 C, anemia w/u, genetic testing • ED – Labs ordered in ED but not yet completed – AM labs ordered (0500) even when labs drawn in ED after midnight

“Being Mindful” 5 Steps Step 2: Will the result of this test change the care of the patient? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163.

Step 2 Examples • • • Repeating procalcitonin daily Repeating CK/CKMB Frequency of electrolytes/H&H Ammonia levels Differential on a CBC H&H vs CBC, BMP vs CMP, K vs BMP

“Being Mindful” 5 Steps Step 3: What are the probability and potential adverse consequences of a false positive result? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163.

Step 3 Examples • D-dimer • Troponin • CHF peptide

“Being Mindful” 5 Steps Step 4: Is the patient in potential danger in the short term if I do not perform this test? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163.

Step 4 Examples • Outpatient testing in the inpatient setting

“Being Mindful” 5 Steps Step 5: Am I ordering the test primarily because the patient wants it or to reassure the patient? Examples? Laine C. High-value testing begins with a few simple questions. Ann Intern Med. 2012; 156: 162 -163.

Step 5 Examples • MRI for back pain • Repeat CXR in patient’s diagnosed with PNA

Commit to Change

Resident Assessment of High-Value Care Sarah Richards, MD Kelly Caverzagie, MD

Next Accreditation System - Aims • Enhance the ability of our peer-review system to prepare physicians for practice in the 21 st century • Reduce the burden associated with the current structure and process-based approach to accreditation • Accelerate the ACGME’s movement towards accreditation on the basis of educational outcomes

ACGME Outcomes Project • Medical Knowledge • Introduced 1999 • Patient Care & Procedural Skills • Professionalism • Implemented 2001 • Interpersonal & Communication Skills • 6 General Competencies • Practice-Based Learning & Improvement • Systems-Based Practice

Struggles moving forward… • Programs had trouble moving from traditional framework (structure/process) to competency framework (outcomes) – Unclear and complex ACGME general competencies – Difficulty in assessing and evaluating resident competence in these general competencies

Think of your training program… • What outcomes do you expect of your trainees? • What are the current outcomes demonstrated by your trainees? • What assessments of trainees do you currently perform?

What are the demonstrated outcomes? • • Superior? Above average? Performs better than peers? Appropriate for level of training? Trainee confidently tells you how he/she did? • Do they match your expected outcome?

IOM High Quality Care • Timely – reducing waits and harmful delay • Efficient – avoiding waste • Equitable – providing care that does not vary in quality because of personal characteristics • Safe – avoiding injuries from care • Effective – providing services based on scientific knowledge to all who could benefit • Patient-centered – providing care that is respectful of and responsive to patient preferences, needs and values

Potential Medicare Outcomes • Work effectively in multiple settings • Coordinate care within and across settings • Understand cost and value of diagnostic and treatment options • Work in inter-professional teams and multidisciplinary team-based models • Identify systematic errors and in implement systematic solutions in case of errors

Internal Medicine Milestones

Family Medicine Milestones

Pediatrics Milestones University of Nebraska Medical Center

Emergency Medicine Milestones University of Nebraska Medical Center

Learners Assessments within Program: • Direct observations • Audit and performance data • Multi-source FB • Chart Stim Recall • ITExam Institution and Program Accreditation: ACGME/RRC Program Aggregation CCC: Synthesis and Judgment Reporting Milestones No Aggregation Faculty, PDs and others Certification Board? ?

Traditional vs. CBME Frenk Lancet, 2010

Entrustable Professional Activity (EPA) • EPA is a strategy for assessment • Work-based = reflect the daily work activities of our profession • Synthetic = integrate multiple competencies • Provide context = meaningful assessment of the work activity

Rules for assessments of trainee: • Measure the expected outcome(s) for a defined activity or rotation • Provide meaning to faculty • Provide meaning to trainee • Provide meaning to CCC (in time) • Reflect needs of our health delivery system

IM-Specific Language • Curricular Milestones provide granular detail for focused assessment and feedback • Reporting Milestones are the outcomes that document developing competence over the course of training

UNMC Example – Hospitalist Medicine Rotation • Day and night rotation for residents in all three years of training • Faculty supervise 1: 1 with resident overnight • Four areas of focus for teaching and assessment: – – High value care Management of acute care issues (RRT, Code, etc…) Patient satisfaction Safe and effective hand-offs at transitions of care • Other clinical care expectations as well!

Why did we choose these areas of focus? • High value care – Nowhere else in residency curriculum, opportunity for DO, faculty expertise • Management of acute care issues (RRT’s, codes) – Opportunity for direct observation by faculty • Patient satisfaction – Faculty expertise, opportunity for DO, nowhere else in residency curriculum • Safe and effective hand-offs at transitions of care – Faculty expertise and implement existing tool

Q-Sort: A Game of Competing Priorities Most important Item 6 – PBLI-D 4 Independently appraise clinical guideline recommendations for bias and cost-benefit Least important Choose 22 applicable milestones from the list of 142 71

Combining, Simplifying and/or Clarifying Similar Milestones • SBP-E 2: Demonstrate the incorporation of cost-awareness principles into standard clinical judgments and decisionmaking • SBP-E 3: Minimize unnecessary care including tests, procedures, therapies and ambulatory or hospital encounters • Uses cost-awareness principles to minimize the use of tests, procedures and therapies that provide no benefit or may be harmful (SBP-E 2, SBP-E 3)

Integrate Existing Literature

University of Nebraska Medical Center

What informs the tool? • Direct observation • Chart Stimulated Recall

Chart Stimulated Recall

High Value Care Assessment • Is an EPA (in our context and for our training program) • Synthesizes multiple domains of competence • Provides granular detail for feedback and learning • Provides meaningful assessment for trainee, faculty and CCC

Questions? Thank you! serichards@unmc. edu kelly. caverzagie@unmc. edu

Practicing High-Value Cost. Conscious Care: One Dime at a Time Lauren Nelson, MD, HO 3 Jason Dinsmoor, M 4

Practicing High-Value Cost. Conscious Care (HVCCC) • Understand the cost and benefits • Decrease unneeded testing • Use cost and comparative data • Customize care based on patient • Identify system level opportunities for improvement ACPOnline. org

• Discuss HVC with patient and family • Identify system improvements • Minimize unnecessary testing • Evidence based medicine

Discuss with Patient and Family • CHOOSING WISELY – IMAGING FOR SYNCOPE • Does she need a CT scan for detection of an Aneurysm? – Lets see what the video says • Does she need to get this test before her insurance runs out? – Lets see what the video says

Discuss with Patient and Family • Have you ever ordered the test anyways? • When have you provided HVCCC through discussion with the patient or family? • Customize a care plan that incorporates the patient’s values and addresses concerns

• Think of an example of something a resident does every day that annoys you? • Can you think of an example with your colleagues? – Annoying? – Opportunity? • Identifying System Improvements

Identify System Improvements • • Collaboration with other specialties Hospital based projects Unit based improvement Resident involvement

Minimize Unnecessary Testing • First understand interventions you are considering • Then decrease/eliminate waste • CHOSING WISELY – PRE OP CHEST XRAY • Would you order the CXR? • What is the potential harm? • When have you personally minimized unnecessary testing?

Minimize Unnecessary Testing What would an intern do….

Minimize Unnecessary Testing -What teaching points can you offer to the intern with regards to HVCCC? -How could physical exam and clinical judgment prevent the ordering of unnecessary tests?

Medication Reconciliation Exercise

CURRENT HOSPITAL MEDICATIONS • • • 1. Aspirin 325 mg daily 2. Diovan 160 mg daily 3. Crestor 40 mg nightly 4. Coreg 6. 25 mg BID 5. Effient 10 mg daily 6. Lantus 35 units SQ nightly 7. Lispro 4 units SQ with meals 8. Glipizide 10 mg daily 9. Metformin 1000 mg BID 10. Nexium 40 mg daily 11. Oxycodone 5 mg/Acetaminophen 500 mg q 4 hours PRN 12. Docusate 100 mg BID

Medication Price Resources • www. costco. com • www. epocrates. com • www. goodrx. com

Evidence Based Medicine • CHOOSING WISELY – D-DIMER FOR VTE • What tools did the attending use to teach the resident? • What techniques do you use? • http: //www. choosingwisely. org/doctorpatient-lists/

Summary • Practicing High-Value Care is the future! – Practice it well – Teach it well – DIME • You can make a difference – Even if it is “One Dime at a Time!”

Questions References: • High Value Care. American College of Physicians, 20 September 2013 http: //hvc. acponline. org/ • Doctor-Patient-Lists. Choosingwisely, 20 September 2013 <http: //www. choosingwisely. org/doctor-patient-lists/> • D-Dimer for VTE. Choosingwisely. 20 September 2013 <http: //bcove. me/o 25 uikla> • Pre-Op Chest X-ray. Choosingwisely. 20 September 2013 <http: //bcove. me/ad 4 fkrf 6> • Imaging for Syncope. Choosingwisely. 20 September 2013 <http: //bcove. me/m 0 d 33 op 8>