The biggest problem with health care costs in the United States is not that they are too high. Nor is it the fact that they are rising. The biggest problem is that we are not getting enough bang for our buck. The United States outspends our peer countries in the OECD two-to-one and we rank the lowest in life expectancy. Therein lies the holy grail of health policy: delivering value—the highest possible quality at the lowest possible cost.
Most clinicans agree that it is part of our responsibility to provide patients with high-value care. Simultaneously, most Americans do not believe health care in our country is a good value. This begs the question, what is going wrong? And, more important, what can we do about it?
Physicians are increasingly compelled to consider costs while caring for patients. In 2013, the incentives are coming from all directions—top-down from policymakers who want more accountability in how we are using resources; bottom-up from patients who want more transparency in how we are spending their money. However, incentives are not enough. We also need to give physicians the skills, training, and support they need to consider costs responsibly.
Most physicians learn very little about health care costs during their training; in many cases, they are specifically taught not to consider costs while caring for patients. The traditional concern is that thinking about costs automatically means sacrificing the ingrained physician ethos to do everything possible for our patients. At the same time, many existing teaching methods may exacerbate the problem by embedding a “hidden curriculum,” leading to costlier diagnostic workups and rewards overutilization.
On the wards, our educational conferences focus on rare cases and our teaching emphasizes exhaustive differentials. We chastise sins of omission frequently and those of commission rarely. In the pre-clinical years, most schools don’t provide in-depth instruction in health economics, payment systems, or cost effectiveness.
What is the path forward? How can we teach cost-conscious care in a way that is both ethically coherent and sufficiently pragmatic? Clearly, there is a critical role for medical education to drive the adoption of high-value care. The “Teaching Value Project” will be a recurring blog series at Wing of Zock aiming to help answer these questions.
—Neel Shah, MD, is a chief resident in obstetrics and gynecology at Massachusetts General Hospital and Brigham & Women’s Hospital in Boston, MA. He is also the founder and executive director of Costs of Care, a grant-funded 501c3 venture. He can be reached at email@example.com.