Got Value? How to Engage Students in Practicing High Value Care

Transcription

1 Got Value? How to Engage Students in Practicing High Value Care AAIM Academic Internal Medicine Week 2014 Heather Harrell, MD Eileen Moser, MD Amit Pahwa, MD Kim Tartaglia, MD Objectives Review the content and structure of the MedU ACP AAIM High Value Care Curriculum for medical students Practice using curricular integration tools, including SOAP V, portfolios, and small group discussion, to integrate concepts of high value care. Identify opportunities to integrate the high value care curricula into existing clerkship teaching

2 Workshop Outline Why Teach High Value Care (HVC) Available Resources MedU/ACP/AAIM HVC curriculum Small group activities for HVC SOAP V Portfolios and HVC Small group Breakouts and Report Out Research opportunities Why Teach HVC to Medical Students? Reality for 21 st century healthcare Pre existing Curricula for Residents and Faculty 3. Students request it

3 Healthcare in America Healthcare costs account for 17% GDP in US 30% of Healthcare spending is on unnecessary or wasteful care = $765 billion annually Physicians direct 87% of healthcare spending in the US Institute of Medicine. Best care at lower cost Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program ; 2012 Preexisting Resources ACP/AAIM HVC for Residents ACP Online Curriculum for Faculty ABIM Choosing Wisely

4 Students want HVC Teaching 2013 AAMC GQ: 38.8% inadequate managed care teaching 62.4% inadequate medical economics Disconnect b/w preclinical teaching and patient care Tackling the hidden curriculum Workshop Outline Why Teach High Value Care (HVC) Available Resources MedU/ACP/AAIM HVC curriculum Small group activities for HVC SOAP V Portfolios and HVC Small group Breakouts and Report Out Research opportunities

5 A New Resource for Medical Students MedU/ACP/AAIM HVC curriculum geared to medical students Online Asynchronous Available FREE* Available at: health/high value care hvc *Due to generous support from the ABIM Foundation, the Josiah Macy, Jr. Foundation, and the Alliance for Academic Internal Medicine MedU/ACP/AAIM Modules

6 Patient Cases Provide Context Medical Students Play Active Role

7 Questions Guide Learning Resource Links Embedded

8 Summary of Key Teaching Points HVC education and Small Groups

9 Cost versus Charge versus Price Cost: an amount that has to be paid or spent to buy or obtain something Charge: a price asked for goods or services Price: the amount of money that you pay for something or that something costs Where can I find costs or charges? CMS Website Healthcare Handbook App Hospital Finance Department Lexi Comp/UpToDate

10 How to Find CMS Fees Fee for Service Payment/PFSlookup/index.html How to Find CMS Fees fee schedule/search/search criteria.aspx

11 How to Find CMS Fees How to Find CMS Fees Fee for Service Payment/ClinicalLabFeeSched/clinlab.html

12 How to Find Average Wholesale Price? NOW WHAT?

13 Small Groups Give students a history and physical Have them write admitting orders Reveal the charges as they order Compare groups to one another SOAP-V Eileen M. Moser, MD, MHPE, FACP Associate Dean for Medical Education Penn State College of Medicine September 12, 2014

14 Learn about a practical application of cost-conscious care Describe a framework to think about clinical decisions in context of value Describe how the SOAP-V tool may be used by learners to promote discussion about value at the point of care SOAP-V Emerged from 2013 Millennium Conference on High Value Care SOAP-V is based on 3 assumptions: To best work, a tool should be easy to use and embedded in workflow Education can help change culture Medical students can be change agents

15 SOAP-V S ubjective O bjective A ssessment P lan V alue High value health care is Improving patient outcomes WHILE Decreasing unnecessary health care costs and harms

16 Benefits OUTWEIGH Risks A high value test or treatment is when Improves outcomes Changes management Meets patients goals Harm to patient Cost to patient Cost to the system 3 Prompting Questions on: 1.Evidence of value 2.Patient values 3.Relative cost

17 1. Evidence of value: Before ordering a test, have you and the team considered whether the result would change management? Before ordering a treatment, have you considered the evidence for the treatment vs. no treatment or an alternative treatment? 2. Patient values: Have you discussed with the patient their goals and values? Do they recognize the potential harm of the test/treatment compared to alternatives? 3. Relative cost: What is the approximate cost of the test/treatment? Are there less costly alternatives with similar benefits? Student Introduction and Faculty Development Short introduction via PowerPoint SOAP-V cards SOAP-V video Students receive a case and practice using role-play

18 Research Project 4 medical schools (Penn State, Harvard- Beth Israel Deaconess, Dalhousie, Case Western-Cleveland VA) American College of Physicians and Carl J. Shapiro Institute as partners Each school with intervention and control arm Pre- and post- surveys on attitudes of medical students, residents and faculty Measuring use of SOAP-V via OSMOSIS app and direct observation Pre-intervention Student Survey % Agree or Strongly Agree Physicians are responsible for considering the potential harms of testing. 100% Physicians should assess the benefits and harms of a test. 100% When making clinical decisions, the cost of a treatment should be considered. 90% Physicians should incorporate patient goals into their clinical decisionmaking. 100% Physicians should not order tests that might provide additional clinical information if those tests are unlikely to alter patient management. 80% Physicians should understand patients out of pocket medical costs. 97% Physicians should take an active role in identifying waste within their own hospital systems. 86% Physicians should not order tests simply to protect themselves against a potential malpractice suit. 54%

19 Pre-intervention Student Survey at 3 Schools % Agree or Strongly Agree Containing costs is the responsibility of every physician. 78% Good care is cost conscious care. 71% I have the power to address the economic healthcare crisis. 42% I have the resources/means to make cost conscious decisions. 55% Diagnostic uncertainty makes me uneasy. 82% I would be comfortable initiating a discussion about unnecessary tests or treatments with my team. 52% I would be comfortable bringing up cost considerations in discussing patients with my team. 60% I make sure I elicit my pts goals and preferences when I interact with them. 93% I incorporate my pts goals and preferences when I make clinical decisions. 88% In my clinical decisions, I consider the potential costs to the patient. 75% In my clinical decisions, I consider the potential costs to the health care system. 51% SOAP-V Collaborators Harvard/Beth Israel Deaconess: Sara Fazio, Grace Huang Cleveland VA: Cliff Packer, Mamta Singh Dalhousie: Ian Epstein Penn State: Eileen Moser, Sue Glod, Dave Richard Shapiro Institute: Grace Huang, Richard Schwartzstein American College of Physicians: Patrick Alguire, Daisy Smith CDIM: Valerie Lang, Sara Fazio

20 Incorporating HVC into Portfolios Heather Harrell, MD, FACP Clerkship Director University of Florida UF Medicine Clerkship Portfolio Required and optional assignments in most competency domains Each student has a faculty portfolio coach HVC assignments are all optional and under the SBP competency

21 Portfolio Assignments Obtain a copy of the itemized charges for your patient s stay and review them with the PCRM to learn about the DRG reimbursement and how much your patient will have to pay. Analyze your* ordering practices of labs, x rays, and other tests for one of your patients and calculate the approximate cost. In retrospect, reflect on whether all these tests were really necessary (e.g. did they change management) and if not, estimate the potential cost savings to your patient. (Include adverse outcome costs as well as monetary.) Conversely, you can analyze whether potentially helpful tests were withheld possibly due to reimbursement/cost issues. *We recognize you don t have control over orders. Pick 1 2 days of one of your patient s hospital stay and calculate the anticipated charges (e.g. fee for the room, tests, medicines, doctor fees, etc.) and compare the coverage that would be provided if the patient had Medicare, Medicaid, or BC/BS and how much the hospital is reimbursed for each of these. Reflection Themes (N=61) Reaction to costs Reaction to ordering practices Reaction to attitudes about the relation of cost and care Payment systems Effect on future practice

22 Costs: Astounding If the goal of this project was to shock students with how much a hospital stay costs, it worked. Of course I had heard all the outrage about how expensive medical care is in the US, but somehow I had never translated that into real numbers. Costs: Small things add up I was able to appreciate the costs inflicted on patients for routine lab tests such as CBC, BMP, etc. Many of these charges although high did not shock me. Looking at the number of those tests ordered did help me realize how a bunch of routine labs can really add up.

23 Costs: Inpatient vs. Outpatient I learned that the cost of labs and tests are significantly higher inpatient versus outpatient. I wonder if this is something that could have been done as an outpatient and could have been cheaper if this had been the case. Costs: Length of Stay An important lesson I am taking from this exercise is that there are substantial financial consequences of deciding to keep a patient overnight. There have been several moments on rounds where this decision was made on a whim with no medical indication. I will remember this exercise when I am faced with a patient with which I could stay an hour later and arrange discharge or keep the patient until morning.

24 Ordering: Mindlessness (cost) Even as a medical student, it was surprisingly easy to order many of these tests without even thinking about the potential costs. I almost wonder sometimes how our ordering practices would change had we been aware of how much exactly each test and drug cost to the patient or their insurance company! Ordering: Mindlessness (medical indication) An intern once told me that he orders daily labs on every patient just to have them. I believe this now to be irresponsible and inconsiderate.

25 Ordering: Role of H&P Unfortunately, a plethora of tests were already ordered and performed before a thorough history was obtained. I thought getting a better history from the patient would have led to the correct diagnosis sooner and more cheaply. Attitudes: Nihilism The health care providers seemed oblivious to her and her financial situation. I feel as though they should have been more aware of her financial situation and that them not knowing worked against her and her family.

26 Attitudes: Patient Effects But it's also irresponsible of us as physicians to lack attention to admission and other intricacies involved in patient cost of care so that we may instead tunnelvision on the unknown diagnosis. In the end, we lose our focus on the socioeconomic difficulties patients face, and if quality of patient care is intricately linked to their ability to thrive after discharge, then throwing an impossible fee and debt in their face innately hurts their quality of life and possibly future care. Payments I had always thought that Medicare paid for everything, but I was surprised to find out that patients still have to pay a deductible. She (case manager) observed that there is little connection between patients bills and what eventually gets paid. The most remarkable thing about the bill was not the amount ($21,183 for four days) but rather the fact that no one could tell me how much it would cost the patient.

27 Payments: Length of Stay There is definitely a financial incentive to not keep the patient in the hospital longer than they need because the hospital can end up having to pay the bill. Now I understand better why hospitals are seeking to shorten length of stay. DRG seemed like a slippery slope. In this I see the value of DRG, chiefly that it encourages hospitals to provide cost effective care. Future Impact I will try to only order tests that will give me the most information or confirm my suspected diagnosis. I will try very hard not to reflexively order lab and imaging tests. I talked to the team about this and the residents and they were amazed by how much savings were possible. They actually did not know why they ordered CBC with differential v. CBC alone! This is how I can save cost for the system, by giving people education and prevention. It s hard to put a number on how much its saves but for me it helped save my friends life.

28 New option Review one of the ACP modules and provide feedback about its relevance (or not) to your training and suggestions for how this could best be incorporated into the medical school curriculum. ACP Module Feedback (N=40) Very relevant to students Recommended integrating concepts throughout medical curriculum Doctoring course (importance of Hx/PE, MDM) Pharmacology (costs of medications) EBM (benefits vs harms cost) Interprofessional small groups Timing prior to residency important to prevent bad habits Shotgun ordering very common experience

29 Themes /Suggestions Little costs add up Inpatient vs outpatient costs (both pricing and different ordering) Seeing actual numbers important Cases very helpful and wanted to interact about them More on defensive medicine More on private insurance Challenge of applying protocols vs individualizing care Student Idea: Create Own 5 things list linked to EBM 1. Don t order a stool culture, O&P or repeat C. Diff toxin test in context of nosocomial diarrhea*. 2. In patients with nephrotic syndrome, do not routinely perform screening for renal vein thrombosis. 3. Screening for hypothyroidism in asymptomatic individuals should not be population based, but should be based on risk factors 4. Patients with acute COPD exacerbations can be prescribed a 5 day course of steroids. 5. Expanding rule 2 from ACP, don t obtain imaging studies in patients with non specific low back pain : role of MRI in patients with sciatica should be limited to preoperative planning.

30 Workshop Outline Why Teach High Value Care (HVC) Available Resources MedU/ACP/AAIM HVC curriculum Small group activities for HVC SOAP V Portfolios and HVC Small group Breakouts and Report Out Research opportunities Small Group Activity Break into groups of 4 5 Discuss following questions: Identify 1 2 ways you could incorporate high value care teaching into your environment Discuss what resources you might use and how you would implement Recognize potential barriers and identify how you might overcome any barriers Report out

31 Summary Very relevant to students and informs habits Seeing actual numbers important and students want to interact about this Incorporates well into patient care (SOAP V) MedU High Value Care Curriculum Expansion of SIMPLE HVC cases Pediatrics (CLIPPS) Family Medicine (fmcases) Radiology (CORE) Finalizing editorial board 1 st working group at MedU meeting 9/30 10/2 Identify curricular gaps Outline cases Begin setting research agenda

32 MedU-ACP-AAIM High Value Care Modules and Objectives (available at Module A Module B Module C Module D Module E Module F Defining High Value Care and the Importance of Clinical Reasoning Statistics and Clinical Decision Making Preventive Care and Value Medications and Value On Rounds: Medical Students, Teams, and High-Value Care Insurance Module A-F A-F A-F A Objective 1. Identify general strategies and specific actions for bringing value into the care of adult patients (things to do and things to stop doing). 2. Identify opportunities to address the problem of waste in the care of adult patients 3. Acknowledge the importance of incorporating patients' individual goals into decision-making 4. Recognize how high-value, cost-conscious care is important for individual patients, the health care system, and society A, B 5. Describe the benefits, harms, and relative costs of interventions for common internal medicine problems A 6. Explain the difference between value versus cost in healthcare. A A A A A A B C C C C C D 7. Acknowledge the marginal benefit of some tests and studies that are frequently performed 8. Recognize that many screening and diagnostic tests are associated with immediate and downstream harms 9. Acknowledge the importance of balancing the benefits and harms of testing 10. Describe a five-step model for thinking about high value cost conscious care. 11. Consider whether the results of a test will alter the patient's management 12. Utilize evidence-based guidelines for the appropriate work-up of common internal medicine clinical scenarios 13. Apply statistical measures to make effective and efficient decisions about diagnosis and treatment 14. Identify four categories of preventive care: Immunizations, screening, behavioral counseling, and chemoprevention 15. Acknowledge that the purpose of screening is to prevent consequences or complications of disease, not just to diagnose disease 16. Identify high quality evidence based tools for promoting preventive care 17. Customize a preventive care plan that incorporates the patient s values and addresses his or her concerns 18. Apply strategies to counsel for change 19. Identify medication cost as an important barrier to adherence

33 MedU-ACP-AAIM High Value Care Modules and Objectives (available at D D D D E E E E F F F F 20. Acknowledge the importance of simplifying medication regimens in improving patient outcomes (stopping non-essential medications and de-escalation therapy) 21. Identify comparative costs of medications (generic vs. non-generic and therapeutic substitutions) 22. Identify resources to assist patients with medication costs and adherence 23. Acknowledge that one s insurance affects the ability to adhere to treatment recommendations (i.e. follow-up, medications, testing) 24. Describe the factors contributing to the problem of health care waste, including the role that students, residents, attendings, and practice venues play in the problem 25. Identify areas of waste within our own hospital system(s). 26. Identify changes at the individual and systems level to overcome barriers to high value care 27. Describe how observing supervising physicians who are not practicing high value care might impact your behavior 28. Describe the basics of health insurance and coverage 29. Describe the difference between cost, charges, reimbursement and cost to the patient 30. Recognize out-of-pocket costs vary greatly depending on insurance status 31. Compare how cost varies across settings of care (office, emergency department, hospital)