High Value Cost Conscious CareKenneth E. Olive, MD FACP
Disclosure• I am Governor of the Tennessee Chapter, American College of
Physicians.• The American College of Physicians promotes its High Value
Cost Conscious Care Initiative
Learning Objectives• As a result of participating in this activity, the participant will
be able to:• Discuss the issue of growing rapidly growing health care
expenditures in the U.S.• Identify factors contributing to these growing costs • Describe the roles physicians may play in helping to effectively
control costs• Discuss common medical practices that increase cost without
providing value to patient care
Key Points• The problem• What is High-Value, Cost-Conscious Care• Five Cases/Five examples
The Problem• Rapidly growing health care spending is a significant U.S.
societal problem• Reducing health care spending by spending in a socially and
fiscally responsible way is an important responsibility of physicians.
U.S. Health Care Costs
1980 1990 20080
500
1000
1500
2000
2500
Billion $
U.S. Health Care Costs
• 2008 Average cost per person $7681• 16.2% of Gross Domestic Product• Gross domestic product (GDP) refers to
the market value of all officially recognized final goods and services produced within a country in a given period.
U.S. Federal Budget
20102013
20162019
20222025
20282031
20342037
20402043
20462049
20522055
20582061
20642067
20702073
20762079
8%
10%
12%
14%
16%
18%
20%
22%
24%
26%
Aging
Excess Health CareCost Growth
Drivers of Entitlement Spending Growth (Percent of GDP)
9
36%
64%
56%
44%
Source: CBO Long-term Budget Outlook, 2010.
Components of Revenue and Spending
Revenues and Financing Outlays
Total Outlays = $3.629 Trillion
2011
10
Total Revenues = $2.230 TrillionTotal Financing = $3.629 Trillion
Individual Income Tax27%
Corporate Tax5%
Social Insurance Taxes23%
Other6%
Borrowing39%
Medicare13%
Medicaid & Other Health
8%
Social Security20%
Other Mandatory15%
Defense19%
Non-Defense18%
Interest6%
Health Care Spending by Country
Percent of GDP (2008)
Source: 2008 Data from the Organization for Economic Cooperation and Development.11
Mexic
o
Turkey
Korea
Luxe
mbourgChile
Poland
Czech
Republic
HungaryIsr
ael
Slova
k Republic
Slove
nia
Finland
Norway
United Kingdom
Ireland
Spain
Italy
Sweden
New Zealand
Canada
Austria
Switz
erland
France
United St
ates
OECD Avera
ge0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Public Private
Reasons Federal Health Expenditures are Increasing• Aging population• Increase cost per beneficiary
• Unhealthy lifestyles• Americans have more resources and are willing to pay more• Fragmentation of payment systems reduces impact of normal
market competition• Patients insulated from cost of care by insurance incentivizing
overspending.
Factors Driving Increased Health Care Spending• New Drugs, e.g. Kalydeco for cystic fibrosis, $294,000/yr, Zyvox
$1400-2000/course of treatment• New Devices, e.g defibrillator, $50,000• New Procedures, e.g. capsule endoscopy, $2000-3000• New Tests, e.g. PET scan, $2000-8000
Conserving health care resources• The U.S. has largely failed to address the
reality that health care spending is increasing at a rate the country can’t afford.
• This is a societal issue that transcends medical care itself—how much should we as a society spend using public funds on health care versus education, the environment, or defense?
Conserving health care resources• At patient-physician level:
• Physicians—in consultation with patients - should use health care resources wisely, based on evidence of safety and effectiveness, the particular needs and circumstances of the patient, and with consideration of cost.
• Physicians should work to reduce utilization of marginal and ineffective services.
What is High-Value, Cost-Conscious Care?• Not just cheap care!• Value – does it provide benefit that outweighs harms?
• Example of high-cost intervention with value: anti-retroviral therapy for HIV infection.
• Example of low-cost intervention with low value: Pre-operative CXR in healthy asymptomatic patients
• High-value care means that health benefits of an intervention justify its harms and costs
• Cost-consciousness takes cost into account as one factor.
Obtaining an exercise ECG (stress test) for screening in low risk asymptomatic adults represents an area of overused testing leading to low value care ?
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Obtaining ECGs for screening for cardiac disease in individuals at low to average risk for CAD represents high value care?
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Annual lipid screening for patients not on lipid lowering drug therapy in the absence of reasons for changing lipid profiles represents an area of overused testing leading to low value care?
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Obtaining BNP measurement in the initial evaluation of patients with typical findings of CHF represents high value care.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Pap smears in low risk women aged >65 and in women who have had a total hysterectomy (uterus and cervix) for benign disease represents an area of overused testing leading to low value care.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Obtaining imaging studies in patients with recurrent, classic migraine headache and a normal neurologic exam represents high value care.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Performing DEXA screening for osteoporosis in women younger than age 65 in the absence of risk factors represents an overuse of testing leading to low value care.
Obtaining a d-dimer, rather than an appropriate diagnostic imaging (extremity ultrasonography, CT angiography, V/Q scan), in patients with intermediate or high probability of VTE to rule out VTE represents high value care.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Obtaining imaging studies, rather than a high sensitivity D-dimer, as the initial diagnostic test in patients with low pretest probability of VTE represents an area of overused testing leading to low value care.
1 2 3 4 5
0% 0% 0%0%0%
1. Strongly Agree2. Agree3. Neutral4. Disagree5. Strongly Disagree
Countdown
10
Case 1• 72 yr old woman with long-standing poorly controlled
hypertension presents with increasing exertional dyspnea and orthopnea for the past week.
• Exam: Temp 98.6, heart rate 110, BP 142/94, wt 175 (up from 165 one month prior. Lungs - bibasilar crackles. Heart – S3 gallop, Legs - 3+ pretibial edema.
• CBC and BMP are normal, initial troponin is 0.01.• ECG reveals sinus tachycardia (rate 110) and LVH.• CXR is consistent with CHF.
Case 1
Case 1• Does a BNP (brain natriuretic peptide) measurement add value
to this patients care?
Does a BNP (brain natriuretic peptide) measurement add value to this patients care?
1 2
0%0%
1. Yes2. No
Countdown
10
Case 1• What is the diagnosis?
Case 1• What is the clinical probability that this patient has CHF?
Case 1• What is the clinical probability that this patient has CHF?• 90%
Case 1• What is the sensitivity and specificity of BNP for CHF?• For levels >450
• Sensitivity=98%• Specificity=76%• American Journal of Cardiology, 2005, 95(8):948-954.
• In someone with a pre-test likelihood of 90% a positive test raises the likelihood to 97%
Case 1• Cost of test ~$30
• What other health care would $30 purchase?• Aspirin 81 mg – 30 days ~$2• Flu shot ~$25• Lisinopril 10 mg qd -30 days ~$4• Carvedilol 12.5 mg bid – 30 days ~$4• Pravastatin 40 mg qd – 30 days ~$4
• If you had to choose would the $30 be better spent on BNP or on the above medications?
Case 1• Other potential uses of BNP
• Diagnosing CHF in unexplained dyspnea,• Diagnosing asymptomatic ventricular dysfunction, • Titrating therapy
Case 1 - Conclusion• Obtaining BNP measurement in the initial evaluation of
patients with typical findings of heart failure does not represent cost-conscious, high value care.
Case 2• 38 yr old secretary presents to the ED with a 2 day history of
non-productive cough, mild shortness of breath, and pleuritic chest pain. She is in generally good health taking not medications. She has smoked one pack per day for 15 years. History of leg DVT at age 26 while on oral contraceptives. She drove back from shopping in Knoxville yesterday. No recent surgery or childbirth.
• Physical exam • Temp 98.8, pulse 80, BP 118/76, resp 16• Appears to be mildly uncomfortable• Chest – some apparent splinting of the left hemithorax with clear
lungs• Heart – normal sounds, S2 normal• Legs – no tenderness, redness, warmth, or edema
Case 2
Case 2
Should this patient have spiral CT with PE protocol to rule out pulmonary embolism?
1 2
0%0%
1. Yes2. No
Countdown
10
Case 2• What is the clinical probability of pulmonary embolism?
Case 2• What is the clinical probability of pulmonary embolism?
Wells Score:
Symptoms of DVT (3 points) No alternative diagnosis better explains the illness (3 points) Tachycardia with pulse > 100 (1.5 points) Immobilization (>= 3 days) or surgery in the previous four weeks (1.5 points) Prior history of DVT or pulmonary embolism (1.5 points) Presence of hemoptysis (1 point) Presence of malignancy (1 point)
Thromb Haemost. 2000 Mar;83(3):416-20
Case 2• Score > 6: High probability • Score >= 2 and <= 6: Moderate probability • Score < 2: Low Probability
• Assume that low probability in this case is 10%
• Spiral CT • Sensitivity70%, Specificity=91%• PV-=3.5, PV+=46• Ann Intern Med 2001; 135:88-97.
• CT cost ~$2000
Case 2• D dimer cost ~$300• Sensivitity = 96%, specificity 40%• PV -=1.1, PV+=15
• Chest 2004;125;807-809
Case 2 - Conclusion• The initial diagnostic test in patients with a low pretest
probability of venous thromboembolism should be a D-dimer rather than an imaging study.
Case 3• 55 yr old male presents to clinic with episode of syncope this
morning. Standing at sink brushing teeth shortly after arising. Felt light-headed and passed out. Unconscious for a brief time only. No preceding chest pain, palpitations, or dyspnea. No focal neurologic symptoms.
• In generally good health except for GE reflux, allergic rhinitis, and BPH.
• Meds: omeprazole 20 mg qd, certrizine 10 mg qd, tamsulosin 0.4 mg (recently started by urologist with first dose last night).
• PE: supine BP 126/84, pulse 70• Standing BP 102/600, pulse 94• Neurologic exam- normal • Cardiovascular exam – normal
• ECG - normal
Case 3• Does he need an echocardiogram as part of his workup?
Does he need an echocardiogram as part of his workup?
1 2
0%0%
1. Yes2. No
Countdown
10
ACC/AHA Scientific Statement on the Evaluation of syncope
Circulation 2006;113:316-327
Case 3 • Echocardiogram cost ~$1200
Case 3 – Conclusion• Routinely performing echocardiography in the evaluation of
syncope is not indicated• Unless the history, physical examination, and electrocardiogram
do not provide a diagnosis • OR unless underlying heart disease is suspected.
Case 4• A 25 yr old woman presents with a one year history of classic
migraine headaches occurring monthly. She sees flashing lights in her left eye followed within 30 minutes by a severe pounding left sided headache accompanied by nausea and light sensitivity. She usually takes naproxen, goes to bed, and it resolves in a few hours. Her gynecologist, who prescribes her oral contraceptive told her these are migraines. She is concerned because an aunt died recently at age 59 of a brain tumor.
• Past medical history otherwise unremarkable.• Meds: oral contraceptive and naproxen prn• PE: BP 108/66, p 68, resp 14, wt 124 lbs• Head and neck exam normal • Neuro exam normal
Case 4• Does this patient need a brain imaging study?
Does this patient need a brain imaging study?
1 2
0%0%
1. Yes2. No
Countdown
10
American Academy of Neurology: Evidence-Based Guidelines for Migraine Headache• Neuroimaging recommendations for nonacute headache:
• Neuroimaging is not usually warranted in patients with migraine and a normal neurologic examination (Grade B).
• Consider neuroimaging in: Patients with an unexplained abnormal finding on the neurologic examination (Grade B) Patients with atypical headache features or headaches that do not fulfill the strict definition of migraine or other primary headache disorder (or have some additional risk factor, such as immune deficiency), when a lower threshold for neuroimaging may be applied (Grade C)
• Neurology. 2000 Sep 26;55(6):754-62.
Case 4• Cost of head CT ~$1500• Cost of head MRI ~$1900• Cost of careful history and physical examination ~$200
Case 4 - Conclusion• Performing imaging studies in patients with recurrent, classic
migraine headache and normal findings on neurologic examination is not indicated.
Case 5• 70 year old woman presents for annual followup visit without
complaints except for wanting to make sure she is up to date on preventive issues
• HTN controlled on benazepril 20 mg qd• Gyn G3P3, two lifetime sexual partners, no history of STDs. As
an adult has had normal paps every 2-3 yrs. Her last was 3 yrs ago. No gynecologic symptoms such as bleeding or pelvic pain. No history of STDs. Widowed and not sexually active.
Does this patient need a Pap?
1 2
0%0%
1. Yes2. No
Countdown
10
Case 5National Breast and Cervical Cancer Early Detection Program , >65
2.8% ASCUS1.0% more severe lesion.2% CIN II or higher
Obstet Gynecol. 1998;92(5):745
Same study in women who had a previously normal Pap
2.2% ASCUS.4% higher grade lesion
Obstet Gynecol. 2000;96(2):219
Heart and Estrogen/progestin Replacement Study – normal pap within two years
2.3% abnormal0.9% high grade cervical lesion
Ann Intern Med. 2000;133(12):942
Women's Health Initiative, ages 50-79
risk of high grade cytological abnormalities (HSIL or cancer) with a normal baseline pap (7.1 per 10,000 person-years
Obstet Gynecol. 2006;108(2):410
Case 5• No published studies have directly evaluated the effectiveness
of Pap screening in older women.• Declining benefit with aging
• other causes of death, • lag time to receive benefit, • false positives, • higher treatment complication rates
Case 5Organization Recommendations for
discontinuingReference
American Cancer Society Women may choose, if ≥70 years and ≥3 consecutive negative tests and no positive tests within last 10 years
CA Cancer J Clin 2002; 52:342
American College of Obstetrics & Gynecology
Age 65-70 years if ≥3 consecutive negative tests and no positive tests within last 10 years
Obstet Gynecol 2009; 114:1409.
U.S. Preventive Services Task Force
Age 65, if not at high risk Agency for Healthcare Research and Quality, Rockville, MD 2003. No 03-515A. January 2003.
Case 5• Pap smears in low risk over age 65 with previously normal
paps provide little benefit.
• General recommendation: • Women aged 65 and older with no increased risk and who
have had adequate prior screening need not undergo continued screening for cervical cancer.
Common Practices with Little Benefit• Routine CBC in adults (56% of visits) - $33 million• Basic metabolic profiles in adults (16%) - $10 million• Annual ECG (19%) - $17 million• Routine urinalysis (18%) - $3 million• Brand name statins instead of generics (35%) - $5.8 billion• DEXA scans for women younger than 65 (1.4%) - $527 million
• Arch Intern Med 2011;171(20):1856-1858.
Common Practices with Little Benefit• Ovarian Cancer Screening – an unproven and possibly harmful
practice• Use CA-125 and transvaginal ultrasound to screen at least
sometimes:• Low risk patients – 28%• Medium risk patients – 65%
• Routinely use CA-125 and transvaginal ultrasound to screen:• Low risk patients – 6%• Medium risk patients – 24%
• Cost estimates: $18-360 million
• Ann Intern Med. 2012; 156:182-194.
Well Accepted Practices with Significant Benefit • 2010 National Health Interview Survey (NHIS)
• Breast cancer screening 72%• Cervical cancer screening 83%• Colon cancer screening 59%
• MMWR. 2012 61(03):41-45
Advice for Providing High-Value Health Care.• Decrease or discontinue use of interventions that provide no
benefit, e.g. routine imaging in patients with low back pain.• Provide interventions that are effective and decrease costs,
e.g. warfarin in high-risk patients with nonvalvular atrial fibrillation.
• For interventions that provide additional benefit at additional cost, assess value by cost-effectiveness analysis.
• Cost-effectiveness should not be the sole determinant of use but should be one factor to receive consideration
• Higher-cost does not always mean greater benefit.
• Ann Intern Med. 2011: 154:174-180.
References• Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines
Committee of the American College of Physicians. High-value, cost-conscious health care concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med. 2011; 154:174-180.
• Brody H. Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List. NEJM. 2010; 362:283-285
• Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012: 156:147-149.