1 / 65

High Value Care at UCSF: Striving to provide the best care at lower costs

High Value Care at UCSF: Striving to provide the best care at lower costs. Christopher Moriates, MD Division of Hospital Medicine GME Grand Rounds, UCSF February 18, 2013. Financial Disclosures. Within the last 12 months, I have received:

sian
Download Presentation

High Value Care at UCSF: Striving to provide the best care at lower costs

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. High Value Care at UCSF: Striving to provide the best care at lower costs Christopher Moriates, MD Division of Hospital Medicine GME Grand Rounds, UCSF February 18, 2013

  2. Financial Disclosures • Within the last 12 months, I have received: • A grant from the ABIM Foundation for a project exploring cost-related curricula in medical education

  3. As an intern, I rotated through the Emergency Department… "To improve emergency room throughput we've replaced the front door with a CT scanner." Cartoon from ACP Internist Weekly Caption Contest 7/3/2012. Caption by Brett Montgomery, MD, from Richmond, Va

  4. How much does this cost? Illustration by Peter Arkle Bloomberg.com 7/11/11

  5. Cost of Headache evaluation • CT Head • Minimum : $750 - (Altus, OK) • Average : $1,150   • Maximum: $4,200 - (Ketchikan, AK) • UCSF: $1,800 - 2,475 • SFGH: $1,800 SOURCE: Newchoicehealth.com (accessed 12/29/11)

  6. Cost of Headache evaluation • MRI Brain • Minimum: $1,650 - (Andrews, TX) • Average : $2,550   • Maximum : $7,300 - (Ketchikan, AK) • UCSF: $3,600 - 6,600 • SFGH: $3,000 - 6,000 SOURCE: Newchoicehealth.com (accessed 12/29/11)

  7. Why show you the costs? • It is part of physician’s professional responsibility to use healthcare resources judiciously • Physicians need to be trained about healthcare costs • Astounding amount of healthcare waste and “unnecessary testing” • It is important to the patient in front of us

  8. Today’s Agenda • Motivations for considering Healthcare Costs • How are we teaching residents? • The UCSF Cost Awareness curriculum • How do you operationalize these ideals? • Highlight Three High-Value Care Projects • How is UCSF addressing this campus-wide? • The Center for Healthcare Value • Conclusions

  9. Slide showing % of GDP goes here?

  10. It Is About The Patient In Front of Us!Side-Effects May Include: Financial Ruin HimmelsteinDU, Warren E, Thorne D, Woolhandler S. MarketWatch: Illness And Injury As Contributors To Bankruptcy. Health Affairs, no.W5(63), 2005. Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009;122(8):741–6. Medical bills are the leading cause for personal bankruptcy in the United States Middle-aged, college-educated, homeowners >75% were insured!

  11. An Uninsured Patient’s Perspective Clip courtesy of This American Life from WBEZ Chicago

  12. …Then The Bill Comes

  13. It is About the Patient In Front of Us:Putting Off Care Because of Cost Percent who say they or another family member living in their household have done each of the following because of the cost: Relied on home remedies or over-the-counter drugs instead of going to see a doctor Skipped dental care or checkups Put off or postponed getting health care needed Not filled a prescription for a medicine Skipped a recommended medical test or treatment Cut pills in half or skipped doses of medicine Had problems getting mental health care ‘Yes’ to any of the above Source: Kaiser Family Foundation Health Tracking Poll (conducted May 8-14, 2012).

  14. Exploding Health Care Costs Since 1987, US health care spending per capita has more than doubled, and the cost borne by patients continues to rise. Chart design: Luke Shuman
Sources: Archives of Internal Medicine, US Centers for Disease Control and Prevention Andy Grove, Wired, 2012

  15. Two separate motivations to consider costs: 1. Macroeconomic resource stewardship 2. Financial safety of the patient in front of us

  16. The Sweet Spot: Where these two motivations align Good for Society Good for Individuals For example: Generic Drugs

  17. UCSF also has an additional motivation… Next Up: “The scariest slide (UCSF) will see all year” – Dr. Mark Smith

  18. The Narrow Network Threat: Consumers want low premiumsand are willing to trade off narrow networks to get them Relative Preference of Benefit Respondents were given a maximum difference trade off exercise in which they were forced to choose the most preferred and least preferred plan feature. Base: All US Adults Less than 65 SOURCE: Strategic Health Perspectives 2012 Consumer Survey Slide from Mark Smith, MD – California HealthCare Foundation

  19. It’s About the Patient In Front of Us: If we don’t figure out at UCSF how to provide our patients and their insurers with higher value care: NO PATIENTS

  20. Previously widely ignored in medical training: “The reasons for this silence are historical, philosophical, structural, and cultural. ...Combating such forces is a tall order, but I believe that medical educators have an obligation to address cost.” - Dr Molly Cooke (2010) Reference: Cooke M. Cost consciousness in patient care--what is medical education's responsibility? N Engl J Med 2010;362:1253-5 :

  21. The ACGME also says so… “Residents are expected to… incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.” - ACGME Under the Systems-Based Practice core competency requirement: The Milestones Project will present many Cost-Related Milestones Reference: ACGME: Common Program Requirements. 2007. (Accessed 10/25/2010)

  22. Introduction to the UCSF Cost Awareness Curriculum

  23. Global Objectives Increase Awareness • To increase medicine residents’ awareness of value, quality, and cost in medicine Improve Attitudes • To improve physician attitudes regarding sustainable spending Change Behavior • Cultivate more cost-effective physician ordering behaviors

  24. Process: How the curriculum is delivered Introduction “Core” topic and case assigned Interns divide into two groups Guideline Review Case Analysis • Review literature • Find evidence based best-practice guidelines • Suggest cost effective workups • Review recent case from our institution • Analyze hospital bill, and clinical chart to evaluate care provided • Reflect on our own clinical behaviors Case review debrief Case based noon conference for ALL residents

  25. Case-Based Noon conference shared with students, residents, and attendings. Includes concrete “Action Items”: 2 things to “Start” and 2 things to “Stop” doing based on the conference

  26. Health Care System IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.

  27. Providing “Value” in Health Care VALUE = Quality Cost

  28. UCSFCost Awareness Curriculum: Evaluation • Pilot: 176 evaluations from 10 conferences • Highly relevant to their clinical practices • (mean, 4.6 +/- 0.6 on a 5-point Likert scale; median, 5) • Likely to change their ordering behaviors • (mean, 4.3 +/- 0.7; median, 4) Moriates, et al. JAMA Int Med, 2013

  29. “ Through modules detailing common admission diagnoses, he emphasizes the principles of evidence-based medicine and provides information about associated costs… ” http://www.nejm.org/doi/full/10.1056/NEJMp1205634

  30. “ …the purpose of this curriculum is not to teach rationing health care; it’s to teach rational health care. By learning the fundamentals of evidence-based medicine, but keeping the best interests of the patient in mind, we’ve learned how to use the most current guidelines to provide individualized yet cost-effective care. Two residents’ experience with the curriculum: ” http://primarycareprogress.org/blogs/16/191

  31. “Choosing Wisely” at UCSF:How Do You Operationalize These Ideals?

  32. Let me tell you about my UCSF Patient… 65 year-old woman with a recent diagnosis of COPD Started on albuterol inhaler 1 month ago by primary doctor She has “attempted to use the inhaler” but has noted increased wheezing and productive cough In the Emergency Department: Started on continuous nebulized bronchodilator therapy, given Solumedrol 125mg, doxycycline, Chest X-ray and CT Chest

  33. So, what happened to our patient? Around-the-clock nebulized bronchodilator therapy (“Nebs”) every 4 hours x 3 days Transitioned to Metered-Dose Inhalers (MDIs) prior to discharge on her last hospital day - Never received dedicated inpatient MDI teaching!

  34. Ms J. - Total estimated hospital bill Summary of current charges Room at $7,277 x4 days $29,108 Pharmacy $3,969 Lab $4,394Supply/Devices $2,272 Radiology $250 CT Scan $2,755 Respiratory Services $4,605 Emergency Room $2,277 EKG $380 Total of Current Charge $50,103 NOTE: Physician fees billed separately

  35. Ms J – Respiratory Care Charges Continuous Nebs per hour = $104 Small Volume Nebs Treatment = $258 each

  36. The Cost During Fiscal Year 2012, the medicine servicealone spent more than $1MILLION on 25,114 nebulizer treatments for 1200 NON-ICU patients UCSF Spent >$3.5MILLION hospital-wide

  37. The Evidence: Nebs vs MDIs Mandelberg A, Chen E, Noviski N, Priel IE. Chest. Dec 1997;112(6):1501-1505. Dolovich MB, Ahrens RC, Hess DR, et al Chest. Jan 2005;127(1):335-371. Turner MO, Patel A, Ginsburg S, FitzGerald JM. Archives of internal medicine. Aug 11-25 1997;157(15):1736-1744 Systematic reviews: No significant difference between devices in any efficacy outcome in any patient group Studies: Bronchodilator delivery by an MDI is equivalentin acute treatment of adults with airflow obstruction.

  38. Patients Misuse Their Inhalers! Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. Journal of general internal medicine. Jun 2011;26(6):635-642. Recent study: 86% of patients misused their inhalers (some did not even take the cap off!) All of them (100%) were able to achieve mastery after training!

  39. UCSF Division of Hospital Medicine High Value Care Committee

  40. Current Philosophy • Focus now on the “low-hanging fruit”: interventions with low or no benefit • Goal: Reduce inappropriate care that does not help (or even harms) patients • Ultimate outcomes: better patient care, reduced cost

  41. iReduce iCalDraw ionized calcium only when needed

  42. The Case of Ionized Calcium (iCal) • Direct Variable Cost at UCSF: • iCal: $20.20 • Serum Ca: $0.49 • In FY2012 the Medicine Service: • 7400 iCal labs • Direct Cost: $149,472 • 40% of all ca+2 labs drawn were iCal • 42% of all iCal labs were drawn on NON-ICU patients

  43. Clinical significance of Low iCal? • Studies suggest: abnormal iCal is likely a marker of illness severity rather than an independent contributor to mortality • Cochrane Review: “There is no clear evidence that IV ca+2 supplementation impacts the outcome of critically ill patients.” • Study involving >58k iCal tests: 75% reduction in iCal lab draws showed no effect on mortality, cardiac arrests, or seizure activity • Egi, M; Kim, I; Nichol, A; et al. Ionized calcium concentration and outcome in critical illness. Critical Care Medicine 2011 vol 39, No. 2 • Forsythe, RM, Wessel CB, Billiar TR, Angus, DC, Rosengart, MR. Parenteral calcium for intensive care unit patients. Cochrane database of systematic reviews (2008)  issue: 4 • Baird, GS, Rainey, PM, Wener, M, Chandler W. Reducing Routine Ionized Calcium Measurement. Clin Chem. 2009 Mar; 55(3): 533-40.

  44. Why Do We Do This? Are We Treating The Patient In Front of Us? Are We Connecting the Evidence to the Care We Provide? Cartoon by T. McCracken www.mchumor.com

  45. High Value Care Committee iReduce iCal: Draw Ionized Calcium Only When Needed APEX

  46. De-STRESS Your Patients Stress Ulcer Prophylaxis Project

  47. Stress Ulcer Prophylaxis Project An Initiative of UCSF Medical Center and the Medication Outcomes Center Stress Ulcer Prophylaxis Project Background/Rationale • Widespread use of stress ulcer prophylaxis (SUP) in the ICU • At UCSF the majority of ICU patients (over 80%) are on SUP and 19% do NOT meet indications for this • Risks associated with therapies include pneumonia and Clostridium difficilecolitis

More Related