Kick up the quality of your care with tips and tactics from Caitlin Clancy MD, coauthor of ACP’s High Value Care Curriculum. We learn to define quality and value in healthcare; the most common barriers to high value care; use of probability and likelihood ratios to boost clinical reasoning and combat diagnostic uncertainty; some useful tools to estimate cost; sources of healthcare waste; and some general pearls on how the healthcare system works…or doesn’t. ACP members can claim free CME-MOC at acponline.org/curbsiders (goes live 0900 EST on podcast release date).
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Written & Produced by: Matthew Watto MD
Hosts: Paul Williams MD, Stuart Brigham MD, Matthew Watto MD
Guest: Caitlin Clancy MD
Quality refers to all the benefits, both immediate and long term, that can be derived from a particular diagnostic test or treatment.
Cost refers to the financial and non-financial harms of a particular diagnostic test or treatment e.g. missed work, physical or emotional suffering, etc.
The above definitions are according to Clancy et al. ACP HVC Curriculum 4.0 Module 1.
One in three healthcare dollars are waste! (Porter ME. N Engl J Med 2010). The top three contributors to spending were unnecessary services, excess administrative costs, inefficient delivery of care. Missed prevention is an honorable mention (Clancy et al. ACP HVC Curriculum 4.0 Module 1).
Clinicians don’t intend to order unnecessary services, but several factors lead to these wasteful practices (Clancy et al. ACP HVC Curriculum 4.0 Module 1).
The uninsured patient lacks the negotiating power (leverage) of a large private insurance company or government institution. As a result, they end up getting charged the inflated face value for diagnostic tests and procedures. This is a common cause of bankruptcy (Clancy et al. ACP HVC Curriculum 4.0 Module 2).
The insured patient pays a monthly insurance premium that is often subsidized by their employer. When they need diagnostic testing or treatment their insurance company negotiates a lower reimbursement rate with the institution providing the needed services. The patient pays their deductible and the insurance company pays the difference. Government insurers can negotiate lower reimbursement than private insurers due to their larger size (Clancy et al. ACP HVC Curriculum 4.0 Module 2).
Large hospital systems often charge insurance companies more for their services than privately owned centers or independent practices because of their large market share and larger operating costs (Philly.com Article on Two Echocardiograms). “Economies of scale don’t translate to lower prices. With their market power bigger providers can simply demand more.” (Elisabeth Rosenthal in her book American Sickness, Rule #7). For example, if insurance company A refuses to pay the high prices charged by hospital system A (who has 60% market share in a region) then insurance company A may lose their customers to insurance company B who remains in good standing with hospital system A.
What we know about insured patients:
Much of the the above data comes from the Oregon Health Insurance Experiment.
Doctors and patients are doing a poor job at being conscious about the cost of care. Only about 1% of healthcare consumers are getting the best prices for “shoppable” tests e.g. an elective MRI (nytimes.com article by Austin Frakt ; http://www.nber.org/papers/w24869).
Here are two resources that allow you to enter a zip code and see the range of prices for a given diagnostic test. Use these resources to determine the fair market price.
Dr Clancy recommends using pretest probability, likelihood ratios and posttest probability to help mitigate diagnostic uncertainty (Clancy et al. ACP HVC Curriculum 4.0 Module 3). The example used on our show included a patient presenting to clinic with suspect heart failure. The pretest probability can be estimated based on a patient’s history, exam and initial data. Next, consider the likelihood ratio (LR) of a given diagnostic test. The magnitude of the likelihood ratio determines its effect on posttest probability. For example, a LR of 2 will raise the posttest probability by ~15%.
LR <5 = small effect on posttest probability
LR 5-10 = moderate effect on posttest probability
LR >10 = large effect on posttest probability
Use the likelihood ratio nomogram to draw a straight line from the pretest probability through the LR to find posttest probability. A test isn’t worth ordering if it is unlikely to change the posttest probability or patient care. Dr Clancy recommended trying the docLogica app, which can help clinicians perform these calculations without a pencil and paper.
Some of the top barriers to high value care include defensive medicine, local culture and patient expectations (Clancy et al. ACP HVC Curriculum 4.0 Module 5). On the show we discussed how to recognize these barriers and use communication and quality improvement projects to overcome them. Clinical decision tools can be added to the electronic health record to help avoid low value practices (e.g. ordering antibiotics inappropriately, making it difficult to order daily labs, or prompting the clinician with questions when ordering a blood transfusion for a hemoglobin above 7). There is some evidence that providing peer prescribing data may lower antibiotic use (Meeker et al. JAMA 2016 PMID 26864410).
Listeners will define and recognize key aspects of high value care including: cost, quality, and barriers to high value care.
After listening to this episode listeners will…
Dr Clancy reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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Love your podcast, recommend it to all the Internal Medicine Residents. Keep up the good work.
Thanks for the feedback!!
Hi there. Longtime listener, frequent recommender, first-time commenter. I like this episode a lot, and I think that Dr. Caitlin Clancy's work is really important. I wanted to nit-pick a little bit on the point she makes about our exceptionally exorbitant health care spending in this country and the major factors that contribute to it. She uses this topic (as many folks in medicine do) to frame the conversation about physician decision-making and how to provide higher value care to patients. I think it's definitely true that physician's day-to-day choices do relate to broader concerns of health care spending, but I think it's importance is really overblown. Or, at least, I should say that the way we practice medicine (deal with uncertainty, order unnecessary testing, etc.) is not what makes our health care system so much more expensive than those is similarly wealthy countries. Certainly we can & should make big improvements in this area, but probably it's an issue facing some other countries' health systems/medical professions as well. And we end up talking about this side of that equation because it's so much easier for us to sink our teeth into and all the other organizational and financial stuff is not something we're schooled or trained in at all. Meanwhile, I think the real problem is that the prices for things in our health system are really jacked up. A really great study was published in JAMA in March of this year by Ashish Jha and some collaborators that sheds some light on this topic. ( https://jamanetwork.com/journals/jama/article-abstract/2674671 ) ( https://www.hsph.harvard.edu/news/press-releases/labor-pharmaceuticals-administrative-costs-health-costs/ ). The reasons for this aberration in our pricing are mostly over my head at this point, since I think they have to do with the institutional structures & economic dynamics among the various entities in the health system (payers, provider organizations, pharmaceutical & device companies, and patients). I think it would be a great idea to reach out and see if Ashish would be interested in doing an episode on The Curbsiders. Cheers, Ben --- Ben Bovell-Ammon, MD, MPH PGY-2 Resident Combined Internal Medicine/Preventive Medicine Program Boston Medical Center/Boston University Medical Center (Pronouns: he/him/his)
Thanks for your very interesting/thoughtful response to the episode. Will be sure to share it with the team. Regards, Matt
Great podcast. how do I get the CME/MOC questions? The multiple choice is not coming up.
Thanks for the feedback - all CME/MOC quizzes are found here: https://www.acponline.org/cme-moc/cme/podcasts/curbsiders
Click on the specific episode you want and there is an option to listen to the podcast and another to take the quiz.
Particularly regarding the issues of insurance vs. hospital bargaining for procedures and other healthcare costs, as well as the issue of price transparency mentioned on this episode, what are your thoughts about the role of Direct Primary Care practices (specifically Direct Primary Care physicians, who would be expected to have a more extensive knowledge base and diagnosis expertise in comparison to DPC by non-physician providers)? I have been hearing a lot about this model lately from other physicians, and enthusiasts really seem to be marketing to patients by addressing these specific problems directly - transparent prices (typically monthly subscriptions) and negotiated "cash prices" for with local lab and imaging services that are below typical negotiated insurance costs. I would love to know what you all think about this.
Thanks for plugging my docLogica project! The more people who use it, the more I'm encouraged to add to it. All the best, - Michael Garfinkle