Session T120 What's this going to cost? Incorporating cost-consciousness in PA education

Chezna Warner MHS, MSW, PA-C Genevieve Delrosario MHS, PA-C Saint Louis University Physician Assistant Education

Objectives 1)Discuss specific reasons behind the increasing importance of cost awareness in healthcare 2)Describe current methods used to integrate cost awareness into health professions education 3)Identify potential tools for their program to begin integrating cost awareness in the curriculum

Why is teaching cost awareness important?

Healthcare decisions/

overall health are affected

Society spends more

Overall health

quality lags

Individuals spend more

Resources are limited

Patient satisfaction/

trust is affected

Society spends more § US spends the largest percentage of our wealth on health care than

any other industrialized nation

§ $2.8 trillion in 2012 § $8915 per person 2012 (2)

§ $9697 per person 2014 (projected) § 7% of federal budget in 1976; 26.6% in 2015 (estimated) (3)

§ Up to 30% of health care spending may be wasted (1)

§ Limited resources are a reality 1.Berwick 2. CMS 2013 3. https://media.nationalpriorities.org/uploads/publications/health.tipsheet.9_16_14.pdf

US health care lags

Individuals spend more

• Health insurance costs to consumers are increasing

• High deductible plans are becoming increasingly common

• Out of pocket costs (beyond deductibles) are

increasing

Individuals spend more § Premiums for employer-sponsored family health coverage increased

3% this year

§ Premiums rose 26 % in the last 5 years §  This is considered slow §  Premiums rose 34% in the preceding 5 years

§ Premiums rose astronomically in the late 1990s and early 2000s (annual double-digit raise) § Worker contributions have more than tripled for individual or family

coverage since 1999

Henry J Kaiser Family Foundation 2014.

http://kff.org/interactive/premiums-and-worker-contributions/

High deductible health plans § An acute change §  20% of workers have HDHP, up from 4% in 2006 §  Akin to homeowners or auto insurance

§ 80% of covered workers have an annual deductible § Average deductible in 2014: $1217 § Up 47% from 2009

§ Calendar year can be an issue as patients “stack” anticipated needs earlier in year

Henry J Kaiser Family Foundation 2014

Out of pocket costs § Beyond premiums, deductibles

§ Over the counter medications

§ Some patients pay more for medications

§ Urgent care used inappropriately increases costs §  + May decrease cost by avoiding ER visit (1)

§  - Access to any care does not mean BEST care §  Can add to costs by diverting from primary care and prevention (2) §  Can add to costs by ending up in ER anyway

§ Delay of care due to cost (3)

1.  Yee, 2.  O’Malley 3.  Bernard and Farr

Resources are limited § Individually

§ Medical problems contribute to at least 62% of bankruptcies (1)

§ As a society

1.Himmelstein 2009

Patient trust, satisfaction affected

§ Cost is relevant to patients!

§ Perception of provider competence

§ Reimbursement tied to patient satisfaction!

§ Particularly relevant to PAs

The bottom line: Overall health is impacted

§ Study of 254 patients with cancer:

§  68% cut back on leisure activities §  46% reduced spending on food and clothing §  20% took less than the prescribed amount of medication §  19% partially filled prescriptions §  24% avoided filling prescriptions

Zafar 2013

The bottom line: Overall health is impacted

§ Study of nonelderly adults with hypertension

§  13% had high financial burdens § Of those with a high financial burden: §  29% delayed care or were unable to get care for financial reasons §  80% identify not getting care as a big problem

§  Self-perceived financial barriers very high among uninsured and those with public coverage

Bernard 2014

The bottom line

AFFORDABILITY = COMPLIANCE

§ Providers can change patient misconceptions about costs if we know costs

§  If providers are aware of impact of high-deductible plans and high out of pocket costs, we can address with patient and increase likelihood of compliance (1)

§  If we know two options are equal but one costs less, we can utilize/promote that option from the start (2)

§ Providers can help patients prioritize expenditures 1. Bernard 2014 2. Okike

Health impact: HDHPs § Discourage or encourage office visits?

§  Especially for those with known chronic disease as they can’t save for emergencies – all HSA $ goes to chronic care (1)

§ HDHPs might improve health behaviors

§ Decreasing cost of care, but not improving or helping quality of care (2)

§ HDHP enrollees are more concerned about reducing cost

§ HDHP enrollees are more likely to be highly-educated

§ They definitely increase patient engagement (interest) in health care costs (3)

1.  Bernard 2011 2.  Reddy 3.  Fronstin

Health impact: HDHPs § However… § HDHPs are a new entity § Research is lacking § Current research is divergent regarding ultimate effect on cost

What are we doing to teach costs to students?

What do we know? § Providers may have limited understanding of costs of therapies ordered(1)

§ Information is not standardized

1. Korn

What do we know? § Brief interventions can improve knowledge and alter behavior (1)

§ Repetitive interventions can improve knowledge and alter behavior (2)

1.  Stuebing 2.  Korn

What do we not know? § Cost of “cheap” or “generic” medications (1, 2)

§ Generic does not equal $4 in all cases § Cost of labs (usually) § Cost of procedures § Cost of imaging § Cost of DME § Cost of medical appliances and equipment – orthopedic

appliances used in OR, CPAP, glucometer strips (3)

1.  Stebbins 2.  Consumer Reports 3.  Okike

What do patients want to know?

§ Cost of medications § Cost of lab tests § Cost of procedure § Cost of imaging § Cost of return visit § Cost of hospitalization § Cost of OP services – referral to specialist, PT,

psychology

Similarities? § Cost of “cheap” or “generic”

medications § Cost of labs (usually) § Cost of procedures § Cost of imaging § Cost of DME § Cost of medical appliances

and equipment – orthopedic appliances used in OR, CPAP, glucometer strips

§ Cost of medications § Cost of lab tests § Cost of procedures § Cost of imaging § Cost of return visit § Cost of hospitalization § Cost of OP services –

referral to specialist, PT, psychology

Where do patients get cost information? § Y-E-N.net – Viagra costs 0.20 euros a pill! § Norcos.org – Norco for 32 cents a pill! § Neighbors, friends § Legitimate sources - states are legislating cost transparency

§ 14 states require insurers to report rates paid to healthcare providers

§ Legitimate websites like Healthcare Bluebook and Fair Health Consumer

§ Patients will have cost information already

Where do we get cost information?

§ Hard to find – numerous pharm apps provide little to no cost information

§ Of the top five medical apps used in 2013, none had

consistent, reliable cost information

§ Direct contact with provider of therapy – pharmacy, imaging center §  Inefficient, variable

Why do we over test or over order?

Why do we over test or over order? § We were not taught not to § Traditional medical education tends to reward

thorough investigation with no nod to cost control (1)

§ Don’t miss the “zebra” § “You may see this one day” § Memorization of minutiae encouraged

§ We don’t have confidence in our clinical skills § Truest for new graduates

1. Detsky

How are medical schools teaching costs? § LCME Standards, March 2014 §  7.2 Organ Systems/Life Cycle/Primary Care/Prevention/Wellness/Symptoms/

Signs/Differential Diagnosis, Treatment Planning, Impact of Behavioral/Social Factors §  “Recognize the potential health-related impact on patients of behavioral and

socioeconomic factors”

§ ACGME Standards § No standard

§  Practice competency: “to incorporate considerations of cost awareness and risk–benefit analysis in patient and/or population-based care as appropriate” (1)

§  Strong support for addition of cost-conscious care as a seventh general competency (2)

1.  ACGME 2.  Weinberger

How are medical schools teaching costs?

§ No specific medical school or residency curricular requirements

§ No evidence or consensus on best methods § Case-based curricula may be utilized in residency §  Fewer than 1 in 6 programs has formal curriculum in this area (1)

§ Various professional resources available § Choosing Wisely (American Board of IM Foundation) §  Less is More (Archives of Internal Medicine) § High Value Cost Conscious Care, ACP

1. Patel

How are nursing schools teaching costs?

§  LPN §  No curricular standard

§ RN/BSN §  No curricular standard from ACIM or CCNE §  More information on teaching nurses (RN level) about core measures/

cost-effectiveness for hospital (Pappas)

§  Education on increasing patient compliance emphasized § NP/DNP §  No curricular standard from ACIM or CCNE

1.  Accreditation Commission for Education in Nursing Standards 2.  Commission on Collegiate Nursing Education Standards 2013

How are pharmacy schools teaching costs?

§  Accreditation standards: §  “Graduates must possess the basic knowledge…to manage human,

physical, medical, informational, and technological resources through the ability to ensure efficient, cost-effective use of these resources in the provision of patient care”

§  Performance competency: Utilize knowledge…in an affordable

manner that meets their health care needs.

1. Accreditation Council for Pharmacy Education Standards, 2016 (Draft)

How are PA schools teaching costs?

§ Primary care orientation of the profession § National organization emphasis on cost-effectiveness of PAs

§ Literature is lacking on subject § Professional standards do not explicitly encourage this instruction

How are PA schools teaching costs? ARC-PA standards:

§  B1.06 The curriculum must include instruction to prepare students to provide medical care to patients from diverse populations.

§  ANNOTATION: Quality health care education involves an ongoing

consideration of the constantly changing health care system and the impact of racial, ethnic and socioeconomic health disparities on health care delivery. Instruction related to medical care and diversity prepares students to evaluate their own values and avoid stereotyping. It assists them in becoming aware of differing health beliefs, values and expectations of patients and other health care professionals that can affect communication, decision-making, compliance and health outcomes.

§  B2.15 The program curriculum must include instruction regarding

reimbursement, documentation of care, coding and billing.

Toolbox! Classroom - Economics

§ Solid health care economics education § One or two focused lectures § Consider early in didactic training

§ Objectives § Understand various health insurance options § Understand increased out of pocket expenses § Understand “intangible” costs – even if patient doesn’t pay, society pays § Understand need to help patients afford necessary care AND avoid

unnecessary care, even if someone else is paying

Toolbox! Classroom - Curriculum

§ Preventive Care § Enhance understanding of cost savings of preventive care §  In-class activities: § Cost of colonoscopy versus treatment for colon cancer § Cost of metformin versus insulin or exenatide § Cost of Pap/WWE versus LEEP § Cost of chlamydia screening versus PID treatment § Cost of TDap versus treatment for pertussis or ER visit for tetanus shot

§ Such activities can be freestanding, or can incorporate diagnosis and management case learning as well

Toolbox! Classroom – Coding and Billing

§ EFFECTIVE coding and billing education §  ARC-PA standard §  Teaching with no basis for comparison may be less effective §  Basics of evaluation and management is feasible

§ Can be done effectively in the clinical year by preceptors (anecdotal)

§  Encourage preceptors to involve students in billing §  Consider education on post rotation days

Toolbox! Classroom Tools

§ American College of Physicians High Value Care Series

§  Integrate similar cases into curriculum with students at the end of didactic training, prior to clinical year

§ Positive – solid, proven, brief intervention § Negative – must avoid “content/curriculum creep” § Need fundamental emphasis at program level to integrate cost

awareness consistently and routinely throughout all areas of development, from first didactic days to post-grad CMEs

Toolbox! Classroom Tools

§ Choosing Wisely §  Physicians who learn about unnecessary testing as a result

of using this tool are more likely to reduce their use of the tests (ABIM survey 5/14)

Toolbox! Classroom

§ OSCE opportunities § Progressively challenging exercises throughout the year

related to costs incurred in the OSCE § Tell us what you did that cost money § Estimate how much it cost § Use a resource to find out how much it really cost § How would you alter a plan if patient had no insurance

and/or can’t pay

Toolbox! Classroom

§ USE AN APP! § Promote use of specific apps and websites developed to

promote guideline adherence, decision making and cost containment

§  ACR- Imaging Guideline app §  ASCCP – Pap management app

§ Most are clinical tools only, often offer little in terms of real costs §  But use can promote learning

§  FairHealth app utilization during lectures

Classroom - IPE § Encourage curricular development of cost

awareness activities in IPTS/IPE programs § Pharmacy education exercise

§ Less is More JAMA cases § Clinical vignettes

§ Improve understanding of cost-effectiveness of our profession

Classroom – and beyond Program Policy

§ Policy implementation to include cost awareness in all areas of PA education § Create a culture of change § Not just another standard to add to your syllabus, but a deeply-

embraced goal for all phases of education § Regulatory influence can be the unifying force

§ Promote online tools for faculty to use when developing lectures, and promote to students for personal and academic use

Classroom – and beyond Preceptors

§ Clinical experience is highly effective § Clinical year develops critical thinking, “putting it all

together” § Preceptors can influence students’ future practice

styles (1)

§ Emphasize Teaching Restraint, Choosing Wisely programs

§ Offer as incentive to preceptors (another advantage of teaching)

1. Hauer

Classroom – and beyond Professional Leadership

§ PA professional organizations can promote cost-consciousness via: § Resource creation ( eg Choosing Wisely) § Regulatory action for professionals and for students §  Promoting legislative and public efforts for cost transparency

“PA education and practice emphasizes chronic care management, preventive care and patient education. These may reduce hospital admissions, readmissions, specialty care and prescription drug use, and in turn eliminate unnecessary costly health services.” (1)

1. AAPA, PAs Increase Access, Quality, and Cost-Effectiveness in Healthcare

Classroom – and beyond Resource Stewardship

§ Professional responsibility to become cost-conscious and avoid unnecessary spending

§ Focus for ethics education

Classroom – and beyond § Choosing Wisely Best Practices § Choosing Wisely Communication Modules § High Value Care Curriculum § Fair Health § Less is More JAMA series

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