Clinical Corner: High-Value, Cost-Conscious Care

Clinical Corner

Steven Weinberger MD, of the American College of Physicians (ACP), gave a presentation on Friday, July 31 at internal medicine conference on the topic of high-value, cost-conscious care. The ACP High Value Care initiative has two aims:

  1. Helping physicians to provide the best possible patient care.
  2. Simultaneously reducing unnecessary costs to the healthcare system.

Here are resources to learn more about this topic:


Choosing Wisely®

www.choosingwisely.org

Choosing Wisely® is an initiative of the ABIM (American Board of Internal Medicine) Foundation, which explores ways to avoid unnecessary medical interventions. The website contains recommendations from over 70 medical specialty societies and health care organizations.


ACP High Value Care

hvc.acponline.org

The ACP High Value Care site contains guidelines and clinical recommendations that address the benefits, harms, and costs of various interventions. There are also curriculum and public policy recommendations, and resources for consumers.


Ann Intern Med. 2013 Jan 1;158(1):55-9.

Design and use of performance measures to decrease low-value services and achieve cost-conscious care.

Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC; American College of Physicians Performance Measurement Committee.

Abstract

Improving quality of care while decreasing the cost of health care is a national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and to determine whether services provide good value. Public and private payers continue to measure underuse of high-value services(for example, preventive services, medications for chronic disease),but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.


Ann Intern Med. 2012 Aug 21;157(4):284-6.

Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum.

Smith CD; Alliance for Academic Internal Medicine–American College of Physicians High Value; Cost-Conscious Care Curriculum Development Committee.

Abstract

Health care expenditures are projected to reach nearly 20% of the U.S. gross domestic product by 2020. Up to $765 billion of this spending has been identified as potentially avoidable; many of the avoidable costs have been attributed to unnecessary services. Postgraduate trainees have historically received little specific training in the stewardship of health care resources and minimal feedback on resource utilization and its effect on the cost of care. This article describes a new curriculum that was developed collaboratively by the Alliance for Academic Internal Medicine and the American College of Physicians to address this training gap. The curriculum introduces a simple, stepwise framework for delivering high-value care and focuses on teaching trainees to incorporate high-value, cost-conscious care principles into their clinical practice. It consists of ten 1-hour, case-based, interactive sessions designed to be flexibly incorporated into the existing conference structure of a residency training program.


Ann Intern Med. 2012 Jan 17;156(2):147-9.

Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care.

Qaseem A, Alguire P, Dallas P, Feinberg LE, Fitzgerald FT, Horwitch C, Humphrey L, LeBlond R, Moyer D, Wiese JG, Weinberger S.

Abstract

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.


Ann Intern Med. 2011 Sep 20;155(6):386-8.

Providing high-value, cost-conscious care: a critical seventh general competency for physicians.

Weinberger SE.

Abstract

There is general agreement that the U.S. economy cannot sustain the staggering economic burden imposed by the current and projected costs of health care. Whereas governmental approaches are focused primarily on decreasing spending for medical care, it is the responsibility of the medical profession to become cost-conscious and decrease unnecessary care that does not benefit patients but represents a substantial percentage of health care costs. At present, the 6 general competencies of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) that drive residency training place relatively little emphasis on residents’ understanding of the need for stewardship of resources or for practicing in a cost-conscious fashion. Given the importance in today’s health care system, the author proposes that cost-consciousness and stewardship of resources be elevated by the ACGME and the ABMS to the level of a new, seventh general competency. This will hopefully provide the necessary impetus to change the culture of the training environment and the practice patterns of both residents and their supervising faculty.


Ann Intern Med. 2011 Feb 1;154(3):174-80.

High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions.

Owens DK, Qaseem A, Chou R, Shekelle P; Clinical Guidelines Committee of the American College of Physicians.

Abstract

Health care costs in the United States are increasing unsustainably, and further efforts to control costs are inevitable and essential. Efforts to control expenditures should focus on the value, in addition to the costs, of health care interventions. Whether an intervention provides high value depends on assessing whether its health benefits justify its costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit. Thus, the challenge becomes determining how to slow the rate of increase in costs while preserving high-value, high-quality care. A first step is to decrease or eliminate care that provides no benefit and may even be harmful. A second step is to provide medical interventions that provide good value: medical benefits that are commensurate with their costs. This article discusses 3 key concepts for understanding how to assess the value of health care interventions. First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value. Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed. Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention.


Kristen DeSanto, MSLS, MS, RD, AHIP

Clinical Librarian

kristen.desanto@ucdenver.edu • 303-724-2121

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