Cost-Consciousness: An Essential Physician Competency

Nick Vailas

Posted 3/05/12 on Healthcare Transparency Now

Only very recently has the medical profession begun to change a professional culture that perpetuates an “evasion of cost consciousness.”

As a Harvard Medical School student recently remarked on a blog, doctors are clueless about the cost of the care.  Physicians must start educating themselves about the economics of their patient care methods. This will require a culture shift.

Research has shown that doctors will change treatment plans once they are aware of the cost of care.  I do believe that given the immense expense of healthcare services that patients can experience extra financial hardship.  I am also aware that the price point difference in services can also be vast so I do believe that doctors, when present treatment and therapy should consider the financial impact of the cost.

Molly Cooke MD is a professor at UC San Francisco Medical School and an expert in medical education.  She wrote an article in the New England Journal of Medicine in 2010 with the title,  “Cost Consciousness in Patient Care — What Is Medical Education’s Responsibility?” The “evasion” quote comes from this article

Addressing in her article her fellow physicians, she wrote, “I would argue that patients depend on us to help them understand both the likelihood that they will experience benefit and the cost, broadly construed, at which that benefit might be won.”

Her prescription?  “First, we must acknowledge the lesson of recent history: creating financial incentives for physicians to behave in ways that are not, or are not perceived to be, in patients’ interest creates distrust and antagonism. We physicians should not gain from doing too little for patients any more than we should prosper from doing too much.

Second, we must abandon the myth of the physician as single-minded advocate for any amount of benefit for every patient.

Third, we must broaden our programs so that all trainees receive a foundation of exposure to health care management and health services delivery, enabling them to participate as informed citizens in the systems in which they work and learn.”

In a subsequent published reply to readers to wrote letters to the editor, Cooke provides an example of cost awareness: “There are substantial opportunities to build into medical education the knowledge and skills that are required for the provision of cost-conscious care. Imagine, for example, a computerized order-entry system that displays the charge for each drug or test at the time that it is ordered and that informs the physician of the daily charges for each patient and the cost of the hospitalization, as compared with the average cost for the principal diagnosis-related group.”

In the first days of this year, the American College of Physicians. through its publication The Annals of Internal Medicine, issued a revised Code of Ethics, in which it said, in a section titled the “changing practice environment,”

“Physicians have an obligation to promote their patients’ welfare in an increasingly complex health care system. This entails forthrightly helping patients to understand

clinical recommendations and make informed choices among all appropriate care options. It includes management of the conflicts of interest and multiple commitments that arise in any practice environment, especially in an era of cost concerns. It also includes stewardship of finite health care resourcesso that as many health care needs as possible can be met, whether in the physician’s office, in the hospital or long-term care facility, or at home.”

In a latter section titled “Patients first and stewardship of resources,” the code of ethics says: “Physicians have a responsibility to practice effective and efficient

health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

A  2011 article by Weinberger recommended a new, seventh competency requirement for physicians:  “cost-conscious care and stewardship of resources: Understand the need for stewardship of resources and practice cost-conscious care, including avoiding the overuse and misuse of diagnostic tests and therapies that do not benefit patient care but add to health care costs.”

In summary, I do believe physicians have a moral obligation to consider the final impact on their patients and be able to offer an alternative that would have the same impact.

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