Cost-conscious care

When he joined the urology faculty at UCLA in 2000, Christopher Saigal, MD, MPH, gave little thought to costs of care.

“At that time, it was all about excellent care and cutting-edge care, the latest and greatest. We didn’t think too much about cost,” said Dr. Saigal, associate professor and vice chair of UCLA’s department of urology.

In fact, cost has not been a big part of the conversation in the history of U.S. health care delivery, according to David Miller, MD, assistant professor of urology at the University of Michigan, Ann Arbor.

“That’s codified to some extent in Medicare policy that often is not allowed to explicitly consider cost,” Dr. Miller said.

Of course, times have changed. Government and private payers, employers, and physician groups are joining the frenzy to rein in what has become out-of-control spending. According to a critical analysis of U.S. health care spending reported in Time, $800 billion of the estimated $2.8 billion the country will spend on health care this year will be paid by the government’s Medicare and Medicaid programs (“Bitter Pill: Why Medical Bills Are Killing Us,” March 4, 2013). “That $800 billion, which keeps rising far faster than inflation and the gross domestic product, is what’s driving the federal deficit,” the article stated.

Since physicians are at the frontlines prescribing care, much of the pressure to deliver cost-effective and necessary care is falling on them. An estimated 60% or more of health care costs are “determined or influenced by physicians,” Shananu Agrawal, MD, of the Centers for Medicare & Medicaid Services noted in a JAMA “Viewpoints” article last month (2013; 309:1115-6).
Urologists, according to Dr. Saigal, need to be involved in creating solutions.

“If we don’t, others will,” he said.

The new reality, according to Dr. Saigal, is that stakeholders are focused on reducing expenses that specialists incur while delivering care. And patients, who in this new paradigm will bear a greater cost burden for their health care, are bound to become more cost conscious.

“We have to understand the argument and provide data for what we do,” Dr. Saigal said. “Everyone knows the health care system is changing, and one of the primary motivators is that health care costs are on an unsustainable path.”

Two approaches to reducing costs
There are two general approaches to reduce health care costs, according to Dr. Saigal. One is the meat cleaver: Reduce fee-for-service medicine reimbursement-across the board. That, he says, could be harmful to patients and result, ultimately, in higher costs. The other approach involves tailoring care so that there is less inappropriate use of services, which would likely improve quality and curb costs.

There is a physician group-backed movement focused on cutting waste, not costs. Choosing Wisely is an initiative by the American Board of Internal Medicine Foundation that encourages specialty societies to submit lists of five procedures, tests, or prescribing practices shown to be ineffective, unnecessary-even harmful. The idea is to educate consumers about these potentially unnecessary medical services, so they can have educated conversations with the very physicians who might be prescribing them.

“These [recommendations] are based on the best evidence, but also require clinical judgment about when there are exceptions or red flags that would warrant recommending these test or procedures,” said Daniel Wolfson, executive vice president and COO of the ABIM Foundation. “This is intended to improve quality and safety and advance appropriate care (quality care). As a byproduct, we maybe will be able to save money.”
The AUA took part in the campaign and released its list of recommendations in February (see, “Choosing Wisely: AUA’s recommendations,” page 1).

“[The AUA] asked me to head up a special group to review our guidelines and to identify interventions and tests that have never really been shown to be, in general, effective, yet, are commonly done and, obviously, incur costs,” said AUA Health Policy Chair David F. Penson, MD, MPH. “It’s about thinking about what we’re doing before we do it, to make sure that we’re not doing unnecessary tests, and we’re not doing unnecessary interventions, which are exposing patients to risk and spending resources we just don’t have.”

Dr. Penson and colleagues referred to the AUA’s evidence-based guidelines and discussed recommendations for the list. Among the final board-approved recommendations: A routine bone scan is unnecessary in men with low-risk prostate cancer. Also: Don’t treat an elevated PSA with antibiotics in patients not experiencing other symptoms. Now, a urologist can use these recommendations the next time he or she is confronted with a patient who isn’t so sure.

The AUA’s participation in Choosing Wisely is key, as many urologists (and physicians in general) are likely to view recommendations and guidelines created by insurers or the government with skepticism, research shows. According to Medscape’s 2012 Urologist Compensation Report, 51% of respondents said they felt treatment and quality guidelines set by insurers and Medicare for shared savings programs will have a negative effect on patient care. In addition, 46% of urologists said they would not reduce testing to contain costs because they believe those guidelines are not in the patient’s best interest.

Their responses closely mirror the report’s overall findings; 47% of all physicians surveyed felt insurer- and Medicare-based guidelines will have a negative effect on patient care, and 43% said they would not reduce testing because they feel the guidelines are not in the patient’s best interest.

“Providers are justifiably wary of quality measures and guidelines which are not developed by other providers from medical evidence, and I think that’s why so many providers responded, ‘No, because the guidelines are not in the patient’s best interest,’ ” Dr. Penson said. “However, if the measures and guidelines are developed properly, they will be in the patients’ best interests and will also, hopefully, result in more cost-efficient health care. It’s incumbent on us as urologists to become more involved in helping insurers and Medicare identify what are the best metrics to use.”

William F. Gee, MD, a urologist in private practice in Lexington, KY, says that insurer and Medicare guidelines are actually payment policies, not guidelines.

“Insurance company ‘guidelines,’ ” Dr. Gee said, “are often written with the interest of the insurance company first; that is, to not pay for certain tests and procedures. This is not in the interest of the patient.”

In contrast, “Specialty society guidelines, and AUA guidelines in particular, are written by urologists and followed by most urologists,” Dr. Gee said.

Changing patient mindset key
Another challenge in cutting costs by reducing unnecessary testing is that patients are often of the mindset, the more testing, the better, according to Dr. Miller.

“One of the classic examples of that and one of the biggest challenges is this issue of imaging for men with early-stage prostate cancer. I think a very legitimate question for patients always is: ‘Won’t these studies help us know whether the cancer has spread?’ ” Dr. Miller said. “Being able to have the conversation with patients and having them as a partner in accepting that there is a lot of data to suggest that some of these tests can be safely omitted [is important]. There is a balance and role to be played by both physicians and patients.”

The value of the AUA’s Choosing Wisely recommendations should trickle down to primary care or internal medicine, prompting the same questions by patients, should their general practitioners prescribe what could be unnecessary tests or treatments. An example is a patient seeing his primary care provider for erectile dysfunction, and a blood test shows his testosterone is normal.

“There really is no evidence that giving him additional testosterone is going to help his erections,” Dr. Penson said. “So, the patient probably shouldn’t be asking for it. The urologist probably knows he shouldn’t be giving it. But, also, the primary care provider needs to know this is not going to help the patient and will just incur costs for little benefit.”

Partnering with payers
Partnering with consumers is one approach; partnering with payers, another.

Dr. Miller is director of the Blue Cross/Blue Shield of Michigan-funded Michigan Urologic Surgery Improvement Collaborative (MUSIC). MUSIC, he says, is one of several programs in BC/BS of Michigan’s Value Partnership Program, which is an innovative model that recognizes physicians as the solution to many of the challenges in health care and efforts to improve care and cost efficiency.

“MUSIC is a consortium of what is now 29 urology practices in the state of Michigan, representing almost 200 urologists. At the heart of our efforts is a clinical data registry, where we collect fairly detailed granular clinical data on patients undergoing prostate biopsies and on patients with newly diagnosed prostate cancer,” Dr. Miller said. “We’re very focused on improving care on a number of dimensions. These include doing our best to optimize the use of radiographic staging studies, like bone scans on men with newly diagnosed low-risk cancers.”

Some of the quality measures might cost more money up front but save costs in the long run, Dr. Miller notes. It strikes a much-needed balance in efforts to reduce spending.

“There’s a sweet spot between quality and cost in many areas,” Dr. Miller said.

Individualized care still reigns, however, despite emphases on what might and might not be necessary and cutting expenses.

“My first and foremost priority, of course, is providing the highest quality, technically excellent, and kind care to patients-making sure patients get the right tests and the right care at the right time,” Dr. Miller said. “With that as my guiding principle, if I think that a test or intervention is in the best interests of the patient, then cost is less of an explicit concern. More globally, I am cognizant of the overall-for lack of a better term-intensity of the care that I provide patients. In other words, thinking critically about whether a patient is likely to benefit from urinalysis or checking a post-void residual rather than having that be something that every patient that comes to the clinic receives.”

Arnold J. Willis, MD, a urologist practicing in Washington, uses the evidence and his own experience as his guides.

“I know in most cases which tests are necessary to treat a specific condition,” Dr. Willis said. “These are the ones I order, and I tend to stay away from many of the newer, more expensive tests, unless they have been shown to clearly improve an individual’s survival, quality of life, or medical outcome.”

More transparency required
Often, physicians don’t know bottom-line costs for tests and procedures. Costs can vary greatly, depending on the payer and whether hospital charges are involved.
“Hospital costs are extraordinarily complicated,” Dr. Saigal said. “It’s hard for me, as a urologist, to ask the hospital what it’s going to cost my patient who has no insurance and needs bladder cancer surgery. It’s kind of like throwing darts to some degree.”

Dr. Gee says information about how much something costs is particularly important to patients who have large deductibles or health savings accounts. And knowledge can save money.

“For example, if such a patient needs a CT scan, the cost can vary widely-from as low as $400 to $500 to over $2,000 in some hospital outpatient facilities. Both scans done on identical GE equipment and read by the same radiologist with the same fee for reading [cost] about $75,” Dr. Gee said.

While keeping costs down is important, urologists might make themselves vulnerable to lawsuits in the process, according to Dr. Gee.

“The challenge is in patients with minimal insurance coverage and no money,” he said, citing patients needing expensive drugs for cancer as a prime example. “A physician must always think of medical liability issues and be very careful not to cut corners with patients with no insurance. You have to do what is right. Cutting corners can lead to being sued.”

Knowledge may not change behavior
With all this said, questions remain whether simply knowing the full costs of what they prescribe will change physicians’ behaviors at all.

Daniel J. Brotman, MD, associate professor of medicine at the Johns Hopkins University School of Medicine in Baltimore, studied whether physicians who are told the exact price of expensive medical tests like CT scans in advance would order fewer of them. In a report published in the Journal of the American College of Radiology (2013; 10:108-13), Dr. Brotman and colleagues found that revealing the costs of CT scans and other imaging tests up front had no impact on the number of tests physicians ordered for their hospitalized patients.

“We, as physicians, have our heads in the sand when it comes to really thinking about the financial impact of what we’re doing. In some sense, that’s noble when in fact you’re dealing with patients, and ultimately the welfare of your patient comes before the financial bottom line for you, your hospital, or for your institution,” Dr. Brotman said.

“However, I think there is a happy medium that can be reached, where providers are more cost conscious, in general, and our payment systems are structured to encourage cost consciousness and avoid wasteful care. Does that apply to urology? Absolutely.”

Have a seat at the table
Whether employed by others or in practice for themselves, urologists should get involved in talking with decision makers about what urologists do and why.
“We have to be the ultimate explainers of the value of urology. People outside of urology often don’t have a good understanding of what urology services are about and why we do what we do,” Dr. Saigal said. “We are in an era of systems-based care and team-based care. We have to be at those committee meetings, within the health system. We have to articulate to the public.”

The days of using expensive technology are by no means gone. But communicating the value of what you’re ordering is critical, Dr. Saigal says.

If urologists communicate value-the impact of services on human health-those services are less likely to be dismissed as “fluff” that could be cut, Dr. Saigal says.

There’s hope, docs say
The paradigm in health care may be changing, according to Wolfson, where the public is shifting from the “more is better” to a “sometimes, less is better” way of thinking. And physicians, he says, are moving from the “why not?” or “why didn’t I order that test?” to “why do I need to order that test or procedure?”

Dr. Saigal says he believes this more judicious use of resources and greater focus on high-value medicine will win out over the meat-cleaver route for reining in health care costs.

“It’s probably better for everybody and for our economy that we’re spending wisely in health care,” Dr. Saigal said. “I’m optimistic that we’re going to end up in a system where urologists still have a strong voice and provide valuable services and are rewarded fairly for their work.”

But for that to happen, he says, urologists will have to become the ultimate educators about why they do what they do.

The bottom line is there is no one perfect pathway to better quality, lower cost care, Dr. Miller says.

“It’s not just evidence. It’s not just clinical experience. It’s both of those, along with collaborative learning and sharing that information,” Dr. Miller said. “We’re the ones in a position to lead that-the opportunities and solutions for achieving higher quality urologic care that in many cases may be lower cost and more sustainable in the long run.”UT