After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it’s often easier and faster to order five tests at once than to order each one sequentially after careful thought.
Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient’s hospital stay.
Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.
“Instead of requesting outside films and outside studies, it’s easier to repeat it,” says Dr. Arora, who serves as director of educational initiatives for Costs of Care. “That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place.”
In a joint editorial entitled, “First, Do No (Financial) Harm,” Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable—consequences for patients.4
Signs of Progress
Calming the “perfect storm” of overutilization will take time and multiple tactics, but hospitalists involved in the effort say they’re starting to see some blue sky. Among the reasons for optimism, Dr. Moriates cites increasingly strong engagement from medical students, residents, and young faculty members and a cultural shift in how providers are viewing care delivery and payment schemes.
Under the Caring Wisely program, established in 2012 at UCSF, he and his colleagues helped launch six projects designed to identify and reduce waste. One major initiative, dubbed Nebs No More After 24, began after the division’s finance administrator informed the group that it had spent more than $1 million in direct costs on nebulized bronchodilator therapies in 2011 for non-ICU patients.5
“We all kind of looked at each other and said, ‘Really? That’s crazy. I had no idea,’” Dr. Moriates recalls.
The medical center, they realized, was spending an inordinate sum despite good evidence that many of the patients could be safely switched from nebulizers to metered dose inhalers.
“That was one of those areas where we found a quick win-win,” he says. After an intervention that included an extensive education effort aimed at patients, physicians, respiratory therapists, and nurses, the division cut its nebulizer rate by more than half and saved roughly $250,000 annually on a single medical ward.
In 2011, Yale’s Dr. Fogerty and colleagues created a friendly competition called the Interactive Cost-Awareness Resident Exercise, or I-CARE, to emphasize the desirability of accounting for both accuracy and cost consideration when working up clinical cases.6 By design, the educational tool rewards medical residents and other providers who reach the correct diagnosis using the least amount of resources.
Instead of requesting outside films and outside studies, it’s easier to repeat it. That just speaks to the fact that we don’t have good electronic systems that actually allow for those care transitions to take place. —Vineet Arora, MD, FHM, hospitalist, University of Chicago, director of educational initiatives, Costs of Care