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

Mexico

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 Average

0%

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

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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

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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

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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

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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

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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

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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

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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

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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

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

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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

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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

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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

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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.