Cost Consciousness Among Medical Practitioners : A Novel Idea?

Ari YeskelPGY-1 MedicineSinai Hospital, Baltimore

June 2013

News Goals Market Costs Future Add’l

Medical Costs – A Hot Topic

News Goals Market Costs Future Add’l

Presentation Goals

1. This is a brief overview of the cost of common diagnostic and treatment modalities in use at Sinai Hospital. Based on data from the April 30, 2013 CDM (chargemaster).

2. The primary goal is to increase cost awareness among medical practitioners.

3. Please note, entire courses of study are devoted to medical billing - this presentation provides a brief overview of the process and is by no means complete

4. Costs presented are the costs billed per the hospital CDM. These costs do not include ancillary fees (e.g., radiology reading, specialty services).

5. Due to difficulty obtaining pharmaceutical costs, I have eliminated drug costs from this presentation.

News Goals Market Costs Future Add’l

Is Healthcare a Market Good? Do you think that healthcare is a market good and is governed by standard laws of supply and demand?

Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

A) Yes, dummy, of course

B) No, it does not apply to medical care

C) Don’t know

D) It doesn’t affect me -- I don’t care

Is Healthcare a Market Good?Do you think that healthcare should be considered a standard market good?

Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

A) Yes, healthcare is no different than any other service

B) No, when it comes to health, money should not matter. What is this, socialism?

C) Don’t know

D) It doesn’t affect me -- I don’t care

Is Healthcare a Market Good?• Current political and medical debates often refer to our medical care as both a right and as a 'market good'

• "In order to consider health care a good that abides by traditional market theory, both consumers and producers should have a reasonable sense of how much the good costs"

• What else in our everyday lives do we either buy or sell with complete disregard for cost?

- Clothes

- Food

- Auto repair

- Buying a home

•Are we really true market providers? Are patients really consumers?

•What happens to the dialogue when healthcare as a market good is broached?

Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

How are Billable Sinai Hospital Costs Determined?

Sources: Hsia RY. Et al. Health Care as a “Market Good”? Appendicitis as a Case Study. Arch Intern Med. 2012;172(10):818-819

A) It’s a free market, man. Sinai can charge whatever they want and negotiate with insurers

B) Government committee sets rates

C) Don’t know

D) It doesn’t affect me -- I don’t care

In Maryland Cost Determination is State-Mandated

“The seven-member commission reviews and approves rates that hospitals can charge for their services …

…Based on a federal waiver from Medicare, the HSCRC sets rates for all payers: private insurance companies, HMOs, Medicare, and Medicaid. This system is referred to as the "all-payer" system because all payers pay for their fair share of hospital costs.”

TAKE HOME MESSAGE

Sources: Overview of Maryland Regulatory System for Hospital Oversight. From http://mhcc.maryland.gov/consumerinfo/hospitalguide/practitioners/index.htm. May 2013,

Zhang, J. Maryland Reins in Hospital Costs by Setting Rates. WSJ. Sept 14, 2009. WSJ.com

News Goals Market Costs Future Add’l

Sinai Resident Survey

Goal: Conduct brief survey designed to gauge our perception of the costs associated with various procedures, tests, and medications at Sinai

Survey: Conducted online through GoogleDocs.

Assessed the following costs: CBC, BMP, Lactate, ABG, CK-MB, Troponin, 12-lead EKG, Portable CXR, Head CT, MRI Head, US of LE, and medication costs

Response: Total of 17 respondents.

Caveats: : Due to a dearth of medication costs within the Sinai Hospital ChargeMaster sheet, medication costs were excluded from the analysis

Winner: Stay tuned until end of presentation

Sinai Resident Survey

Surprisingly, on the whole, residents tend to overestimate costs

Cost -Overview

$-

$400.0

$800.0

$1,200.0

$1,600.0

$2,000.0

CBC BMP Lactate Level ABG CK-MB Troponin 12 Lead EKG Chest XR -Portable

Head CTScan (w/o)

MRI head(w/o)

US of lowerextremities

(BL)

Mean

True Value

On average, we overestimated the cost of a CBC by 160%

Cost - CBC

Mean, $38.4

CBC, $14.6

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

CBC

Mean

True Value

CBCMean 38.4$ Max 90.0$ Min 10.0$ Std Dev 22.8$ True Value 14.6$

Residents inflate cost of BMP by 90%

Cost - BMP

Mean, $38.8

BMP, $20.2

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

BMP

Mean

True Value

- BMPMean 38.84Max 100Min 8Std Dev 23.01True Value 20.17

Sinai residents only mildly inflated lactate costs (22%)

Cost - Lactate

Lactate Level, $36.6

Mean, $44.3

$-

$10.0

$20.0

$30.0

$40.0

$50.0

$60.0

$70.0

$80.0

Lactate Level

Mean

True Value

- Lactate LevelMean 44.26Max 100Min 5Std Dev 25.46True Value 36.6

We underestimated the true ABG cost by 50%

Cost - ABG

Mean, $87.6

ABG, $156.2

$-

$20.0

$40.0

$60.0

$80.0

$100.0

$120.0

$140.0

$160.0

$180.0

ABG

Mean

True Value

- ABGMean 87.58Max 250Min 1Std Dev 62.51True Value 156.19

CK-MB estimates were 66% higher than true values (but with exceptionally high std dev)

Cost - CK-MB

Mean, $76.1

CK-MB, $45.8

$(20.0)

$-

$20.0

$40.0

$60.0

$80.0

$100.0

$120.0

$140.0

$160.0

$180.0

CK-MB

Mean

True Value- CK-MBMean 76.05Max 300Min 3.99Std Dev 79.66True Value 45.78

Likewise, troponin estimates were 95% higher than true values (with exceptionally high std dev)

Cost - Troponin

Mean, $89.3

Troponin, $45.8

$-

$20.0

$40.0

$60.0

$80.0

$100.0

$120.0

$140.0

$160.0

$180.0

Troponin

Mean

True Value- TroponinMean 89.32Max 300Min 3.99Std Dev 81.81True Value 45.75

12-Lead EKG Cost Estimates Were 80% Higher Than True Values

Cost - EKG

Mean, $80.9

12 Lead EKG, $44.2

$(50.0)

$-

$50.0

$100.0

$150.0

$200.0

12 Lead EKG

Mean

True Value- 12 Lead EKGMean 80.89Max 300Min 5Std Dev 93.08True Value 44.2

We overestimated the cost of a portable CXR by 50%

Cost - CXR

Mean, $138.6

Chest XR - Portable,

$90.3

$-

$50.0

$100.0

$150.0

$200.0

$250.0

Chest XR - Portable

Mean

True Value

- Chest XR - PortableMean 138.63Max 350Min 13Std Dev 98.71True Value 90.3

Residents’ estimates of CT head exam were 600% higher than the actual cost

Cost - CT - Head (W/O)

Head CT Scan (w/o),

$124.0

Mean, $877.0

$-

$200.0

$400.0

$600.0

$800.0

$1,000.0

$1,200.0

$1,400.0

$1,600.0

$1,800.0

Head CT Scan (w/o)

Mean

True Value- Head CT Scan (w/o)Mean 876.99Max 3000Min 150Std Dev 782.16True Value 124

Our estimates of an MRI were 163% higher than actual cost

Cost - MRI Head (w/o)

MRI head (w/o), $689.7

Mean, $1,811.7

$-

$500.0

$1,000.0

$1,500.0

$2,000.0

$2,500.0

$3,000.0

$3,500.0

MRI head (w/o)

Mean

True Value

- MRI head (w/o)Mean 1811.68Max 5000Min 425Std Dev 1308.11True Value 689.72

In contrast to most tests, we underestimated the cost of an ultra sound by nearly $300

Cost - US of LE (bilateral) w/ doppler

US of lower extremities (BL), $633.0

Mean, $347.4

$(200.0)

$100.0

$400.0

$700.0

$1,000.0

US of lower extremities (BL)

Mean

True Value- US of lower extremities (BL)Mean 347.42Max 1000Min 80Std Dev 225.66True Value 633

COPD Patient: Typical Presentation

HPI:

Mr. ES is a 60 y/o man with COPD, obstructive sleep apnea, and CHF who presents to Sinai with a of a 1 to 2 day history of worsening shortness of breath and mild cough. He had increased orthopnea and diffuse chest discomfort; also some diffuse abdominal pain. The patient is on 3 liters per minute of oxygen at home and nocturnal CPAP for obstructive sleep apnea and is apparently compliant with these. On admission an arterial blood gas showed pH 7.3, PCO2 78, PO2 58. CXR showed no evidence of acute processes and CBC was WNL. During the course of the patient’s ER stay, the patient developed respiratory distress, was placed on BiPAP, IV steroids, bronchodilators, lasix and admitted to the ICU.

Billable items

- CXR

- ABG

- BMP

- CBC

- Sputum Cx

- CPAP (12 hr)

- ICU Admission:

$60.34

$156.19

$20.17

$14.62

$73.26

$243.13

$ ???

TOTAL (10 minutes) : $568

Septic Patient: Typical Presentation

HPI:

This is a 57-year-old man with short gut syndrome who was transferred to the ICU for hypotension. The patient presented to the hospital on 04/02/2013 with electrolyte imbalance, acute kidney injury associated with dehydration, and increased ileostomy output. His electrolytes were corrected and he was hydrated with improvement in his renal function and he also had GI infections ruled out. He was scheduled for discharge home today, but began having fevers and leukocytosis (peak 51K). He was cultured and started on empiric broad-spectrum antibiotics (and subsequently became hypotensive. Overnight he received IV fluids, but remained hypotensive and was therefore transferred to the ICU for further management and vasopressor support. He also had transient hypoxemia that was felt to possibly be due to volume overload. He was therefore given Lasix. Currently he is feeling well without specific complaints.

Billable items

- CXR (portable):

- Sputum Cx

- Urinalysis

- Urine culture

- Lactate (q4 x 10)

- Blood culture

- CBC

- BMP

$90.47

$73.26

$7.3

$54.9

$36.6

$73.26

$14.62

$20.17

TOTAL (5 minute) : $370.58

Daily Blood Draws: Modern-day blood letting ?

Sources: Hobson, K. Reducing Unnecessary Blood Tests By Telling Doctors the Cost. WSJ. March 16, 2011. WSJ.com

Daily Blood Draws: Costs at Sinai

Sources: National Center for Health Statistics. Health, United States, 2012: With Special Feature on Emergency Care. Hyattsville, MD. 2013.

•Average length of stay in NorthEast = 5.4 days. In South = 4.9. Given Baltimore is in the geographic middle, we take the average of these two values and use 5.15

**Wisser, D et al. Blood Loss from Laboratory Tests. Clin Chem. 2003 Oct;49(10):1651-5.

Average length of stay*

5.15 days

CBC = $14

BMP = $20

Mag = $11

Phos = $3

$178CBC = $14.62

BMP = $20.17

Average length of stay*

5.15 days$253

FL

OO

RS

ICU

CBC = 2.4ml **

BMP = 4.7ml **

Average length of stay*

5.15 days

36ml

News Goals Market Costs Future Add’l

Next Steps: How can we increase awareness/decrease costs?

Incorporate ‘cost consciousness’ as a part of medical education (e.g.,

presentation at orientation, badge additions, lists of common exams)

Ordering systems (Hopkins) that show costs when ordering tests,

etc.

Empowering patients to be active participants in care

Changing the system – less disconnect between providers,

payers and patients

Add actual antibiotic costs to Sinai antibiogram (in lieu of $$$$)

Hypothetical allowance per year for house staff

Your input here….

Next Steps: (Debatable) Suggestions for Changing Habits Based on Cost

• Are serial lactate exams always necessary?

• What about (free) anion gap that if normal predicts a normal lactate level and if abnormal predicts an elevated lactate level

• Is a BNP always necessary?

• Does a good physical exam better predict abnormal heart pressure than a lab test?

• For back pain patients, is there a real rationale for an MRI when a CT will suffice?

• For COPD patients, what is the role of serial CXRs? Are they necessary?

• Other suggestions?

News Goals Market Costs Future Add’l

Appendix: Imaging - Common Exams Imaging-MRI

MRI BRAIN W/CONTRAST 498$

MRI ORBIT FACE NECK W 575$

MRI ABDOMEN WOW 958$

MRI BRAIN(INC STEM) 383$

MRI/CERV/SPINE WOW 690$

MRI LUMBAR SPINE W/O CONTRAST 383$

MRI LOWER EXTREMITY 575$

MRI ABDOMEN 766$

MRI PELVIS 690$

MRA BRAIN W/O 690$

MRA NECK W 690$

MRI/CERV/SPINE WOW 690$

MRI KNEE WOW 575$

Imaging - XRCHEST X-RAY PA&LAT 60$

XR-C SPINE 2 VIEWS 91$

XR-GASTRONGRAFIN SWALLOW 181$

ABDOMEN SINGLE AP VIEW 90$

KNEE AP & LAT VIEWS BILAT 90$

PORTABLE CHARGE 30$

SMALL BOWEL SERIES 181$

Imaging-CTCT HEAD/BRAIN W/O 124$ CT HEAD/BRAIN WO/W 207$ CT HEAD/BRAIN W 157$ CT THORAX W/O 165$ CT THORAX W/ 207$ CT ABDO W/O 165$ CT ABDO WOW 273$ CT ABDO W 207$ CT PELVIS W/O 165$ CT PELVIS WO/W 273$ CT CERVICAL SPINE W 207$ CT LUMBAR SPINE W 207$ CT/ABD AND PELVIS W 413$

Imaging - US

BILAT VENOUS IMAGING W/DOPPLER 633$

ARTERIAL DUPLEX SCAN 1,266$

VENOUS IMAG W/DOPLE LWR EXTR 332$

VENOUS IMAG W/DOPPLER UPR EXTR 331$

ANKLE BRACHIAL INDEX (ABI) 60$

US-ARTERIAL DUPLX LE BILAT 633$

US-ARTERIAL DUPLX UE BILAT 422$

US-VENS IMG W/DOPLR UE BILAT 633$

US-VENS DOPLR LE BILAT LIMITED 327$

Imaging - NMVQ STUDY 181$ BONE SCAN (WHOLE BODY) 205$ PET/CT ONCOLOGY WHOLE BODY 1,895$

CODE / EMERGENCYCPR 1-15 MINUTES 33.07CPR 30 MINUTES 66.14CPR 45 MINUTES 99.22CPR 60 MINUTES 132.3CRASH CART ADULT 360.51

Appendix: Costs by common tests by specialty (April 2013)

CARDIACCK-MB 46$ TROPONIN 46$ MYOGLOBIN 37$ BNP 55$ PRO-BNP 46$ 12 LEAD EKG 44$ STRESS TEST 69$ STRESS ECHOCARDIOGRAM 206$ ECHO M-MODE & 2D 103$ ECHO TRANSESOPHAGEAL 137$

PULMSIMPLE SPIROMETRY $ 202 SPIROMETRY W/BRONCHODILATOR $ 413 BRONCHIAL PROVOCATION $ 659 PF/HAND-HELD NEBULIZER 105$ PULSE OXIMETRY CONTINUOUS 352$ CHEST PHYSIOTHERAPY 16-30 MINUTES 81.9$ MECH VENT INITIAL DAY<12HRS 309.38MECH VENT INITIAL DAY>12HRS 530.43MECH VENT SUBSEQ DAY <12HRS 276.27MECH VENT SUBSEQ DAY >12HRS 464.11CPAP INITIAL DAY<12HRS 243.13CPAP INITIAL DAY >12HRS 375.67CPAP SUBSEQ DAY <12HRS 187.85CPAP SUBSEQ DAY >12HRS 320.45

EndoPARATHYROID HORMONE 27$ PROLACTIN 37$ TESTOSTERONE 27$ FREE T3 27$ FREE T4 27$ THYROGLOBULIN 46$ TSH (3rd Gen) 27$ HBA1C (Glycohemoglobin) $ 37 POC Glucose monitoring $ 7

HematologyFACTOR VIII 110$ FACTOR V 110$ FACTOR VII 110$ D_DIMER 27$ HBG ELECTROPHORESIS 46$ RETICULOCYTE COUNT 18$ DIFFERENTIAL (BLOOD) 18$ HAPTOGLOBIN 27$ LDH 7$ FERRITIN 27$ IRON (SERUM) 11$ BLEEDING TIME 27$ SEDIMENTATION RATE 11$ THROMBIN TIME 18$ PROTHROMBIN TIME 15$ FACTOR VIIA/1 ML 2,371$

ID / SpecimensCULTURE BLOOD 73$ CULTURE SPUTUM 73$ CULTURE URINE 55$ SENSITIVITY - BACTERIAL 18$ URINALYSIS 16$ C DIFF TOXIN 46$ C DIFF AMPLIFIED 74$

Basic LabsCBC 15$

BMP 20$ CMP 27$ DIFFERENTIAL 7$ HEPATIC FUNCTION PANEL 20$ LIPID PANEL 34$ GASTRIC OCCULT BLOOD 7$ C-REACTIVE PROTEIN 27$ LACTIC ACID $ 37

TransfusionBLOOD-1 U 694.14BLOOD-2 U 1041.19BLOOD-3 U 1388.22PLATELETS-1 BAG 694.14PLATELETS-2BAGS 1041.19

Next Steps: Further Analyses

• Obtain detailed cost information from Sinai Pharmacy for most common medications grouped by genre (e.g., cardiac medications, antibiotics)

• Create new antibiogram with quantitative costs (per unit)

• Create cost awareness cards to be placed on badge with most commonly prescribed tests and associated costs

• Suggestions…

… AND THE WINNER IS…