Cutting Healthcare Costs: Searching – Ever So Gingerly – For the Right Words

During my med school psychiatry rotation, I was taught not to shy away from discussing suicide with a depressed patient. “You won’t be suggesting something they haven’t thought about,” my professor told me back in 1982. “By not raising it, you add to the sense of stigma and it just becomes the elephant in the room.” I later came to appreciate that discussing dying with patients nearing the end of life is much the same.

From these experiences, I learned that while it’s completely natural to tiptoe around difficult issues, it’s sometimes the wrong approach. I wonder whether we’re making this mistake when it comes to discussing healthcare cost reduction. As with the depressed or dying patient, speaking in code is always risky, since it gets in the way of honest, straightforward dialogue. Moreover, in this case, using squishy language may open the door for misunderstandings, even obfuscation – such as when efforts to save money are clothed in the more politically acceptable garb of quality.

Here is that proverbial elephant: Everybody knows that the costs of healthcare are unsustainable. Everybody knows that while we’ll start off on a perfectly reasonable – and non-controversial – mission to remove “waste, fraud, and abuse” from the system, we’ll eventually have to confront hard questions regarding high-cost/low-value tests and treatments. And everybody knows that the final outcome of this will be rationing, in one form or another. The math simply doesn’t work out any other way.

But talk of “death panels” has created such timidity that well-meaning people and organizations are searching for euphemisms for their sensible – critical, actually – cost-reduction initiatives. For example:

  • The American College of Physicians recently announced a new push for “parsimonious care,” which sounds like something the aristocrats on Downton Abbey might say.
  • The ABIM Foundation’s campaign – which has signed up more than a dozen specialty societies, all pledging to reduce the use of certain low-yield procedures or tests – goes under the name of “Choosing Wisely.” Who could be against choosing wisely?
  • The Archives of Internal Medicine has been running an influential series called “Less is More,” bringing to mind the famous “reversible raincoat” school of speechmaking, whose apogees were “Ask not what you can do for your country…” and “The only thing we have to fear…”
  • “Lean” aficionados focus on “removing muda” (Japanese for “waste”), which is drawn from Toyota Production System lingo and thus seems foreign and a little exotic. But it has several disadvantages: first, muda sounds dirty in English, and second, Toyota’s reputation for building perfect cars is no longer, well, unsullied.

Whatever the words, the typical appeal is to the individual – this costly care will harm you, Jane Q. Patient – rather than to the need to eschew low-value care (or, as recently proposed by Larry McMahon and Vineet Chopra of the University of Michigan, making patients responsible for the costs of low-value care out of their own pockets) for individuals in the name of benefiting the entire population. While framing things in the former way in individualistic America is politically astute, we need to face facts: most Americans believe they should have access to whatever treatment might work, and they view skeptically anyone who stands between them and this right. During my recent sabbatical in London I was amazed by the degree to which British patients and families simply accepted the doctor’s paternalistic declaration that there were no more curative arrows in his or her quiver. In my experience, most American patients don’t buy it – they want a second opinion and an MRI.

The hopes of achieving cost reduction by appealing to individual patients’ self-interest may also run into the buzz saw of our national Culture Wars. A recent article by UCSF geriatrician Eric Widera and colleagues reviewed patients’ attitudes toward “miracles” in their care. In one survey, 57 percent of Americans believed that divine intervention from God could save a person, even if the physician deemed further care to be futile. In such an environment, a doctor who says, “I’m sorry, there’s nothing more we can do,” can be accused of being not only anti-hope, but anti-God.  (By the way, this belief in miracles has its, er, genesis in both religion and television: one study found that Americans believed that in-hospital CPR had a success rate of about 70 percent, precisely the success rate of Codes on medical TV shows [the actual success rate is about 15 percent]. If before the Code Blue the TV doctor or nurse said, “it would be a miracle” if the patient survived, the post-CPR survival rate was 100 percent.)

And so we just keep doing, bringing our country a little closer to financial ruin with each passing day.

Our careful language regarding cost reduction carries the risk of rendering our conversations on this topic opaque, which is what usually happens when we’re not quite saying what we mean. Against that background, you can bet that some folks (read: payers) will begin framing cost savings as being about quality or safety; i.e., the numerator, not the denominator of the value (quality divided by cost) equation. They will be correct some of the time, such as when we reduce the number of unnecessary CT scans or unwarranted stents. At other times, though, such language will allow people and organizations with cost-cutting agendas to shield themselves from owning up to their part in this challenging but critical debate.

And it will be awfully hard to tell these two circumstances apart.

We’ve seen this movie before. In the early days of managed care, when the science of quality measurement was far less mature than it is today, some healthcare insurers included C-section rates and hospital lengths of stays among their “quality measures.” Since no one knows the “right” rate of C-sections or number of hospital days, these really aren’t quality measures; they’re measures of resource use. In 2007, physician groups in New York State successfully challenged Aetna, CIGNA, and United HealthCare on the grounds that their MD “quality ratings” (used to create tiered physician networks) were actually unadulterated measures of expenditures.

And last month, the National Quality Forum, an organization whose raison d’être has traditionally been to vet and certify quality and safety measures, endorsed several “resource use” measures involving cardiovascular, diabetes, and overall primary care. NQF didn’t explicitly say that it was getting into a new ballgame – that of cost or waste reduction – but rather, in the words of senior VP Dr. Helen Burstin, that “cost and quality need to be reported together.” The NQF uses robust methods and has broad participation, and so its entry into the cost reduction arena is great. But when an organization whose name is “Quality” turns its attention to resource use, it won’t be long before some claim that performance on these new measures reflects a practice’s quality rather than its costs. It might or might not.

The problem, you see, is that less sometimes is more. But sometimes, less is less.

There are likely to be many cost-reduction efforts that don’t harm quality, safety, and the patient’s experience – and even some that improve them. Fantastic – we should be doing everything we can to identify these areas and make them happen. The fact that America’s premier healthcare organizations are finally addressing the staggering costs of care is a most welcome development. And their decision to choose their words carefully while traversing a political terrain strewn with landmines is completely understandable.

But ultimately, we will need to come to grips with the need to call it as we see it. We must bend the cost curve quickly and sharply, and that will invariably entail some hard choices. To make those choices thoughtfully will require lots of information about both the numerator and the denominator of the value equation, and correct interpretation of these data will demand a gimlet-eyed understanding of which part we’re talking about. Getting this right is less about quality, parsimony, or wisdom than it is about self-preservation – of our healthcare system and our national economy.

7 Responses to “Cutting Healthcare Costs: Searching – Ever So Gingerly – For the Right Words”

  1. Menoalittle March 1, 2012 at 2:51 am #

    Bob,

    Superb and thoughtful. EHR devices fit well in your thesis since they are expensive and are not exactly bending the cost curve or improving outcomes.

    In an effort to achieve those divine cybernetic miracles people and politicians want, the United States is handing out $ billions to physicians and hospitals to entice them to deploy EHR, CPOE, and CDS care instruments. That is strange because these devices have not any track record for being safe, efficacious or usable. The meaningful use dogma is meaningful ruse.

    At a time of national austerity, how did the HIT vendors convince Congress to waste the $ billions? By the way, the greatest dangers, waste, disruption, and abuse of professional time lies within the CPOE devices.

    UCSF spent a few bucks on a GE Centricity system of care record devices that would probably have saved more lives had it been earmarked for nurses and medications for the indigent. Since the deinstallation, another device maker has come on the scene.

    How much has UCSF spent on the goal of achieving cybernetic miracles, Bob?

    Has UCSF chosen wisely? Who is paying, exactly? More MRIs?

    Best regards,

    Menoalittle

  2. Hogtied78 March 1, 2012 at 4:14 pm #

    Bob;

    Excellent as usual, but your focus is on the wrong groups. At our little hospital here in bucolic NH, the CEO owns every physician. No referrals are allowed out of network, enforced implicitly with salaries dramatically higher for physicians than anything else in the area. It is The Night of the Walking Dead with the patients as the victims and the physicians as the zombies, comtrolled by a sociopath. Money is spent at the whim of the CEO, and the Board of Directors are as impotent as Viagra failures. The amount of money wasted is frightening. And it is all legal. The OIG is not knocking at the door.

    Unfortunately, the race to buy physicians is intensifying. In most cases, it is not such a bad thing. In our case, it has adversely affected the quality of care in the community. You have an open invitation to come by our beautiful town, and see what a boss Tweed has done to the medical community here. It is more frightening than the actual movie.

  3. Bev M.D. March 1, 2012 at 5:48 pm #

    Excellent post. What you are saying is that we have allowed the radicals to frame the discussion, so that everything said now must be said from a defensive position. I agree with you that this issue is way, way too important to allow that to happen. Thoughtful but direct discussion such as you advocate is the only way to ‘take back’ the prospect of rational debate on the subject.

  4. Kerry O'Connell March 1, 2012 at 7:39 pm #

    The Elephant is really simple. Doctors are indifferent to Healthcare costs because ” Insurance is Paying” . Patients are indifferent to Healthcare costs because ” Thank God Insurance is paying” Insurance Carriers are indifferent to Healthcare costs because ” It is oh so easy to jack up insurance rates”. Instead of insuring everyone insure no one then watch how fast they all begin to care about costs.

  5. Mark May 8, 2012 at 12:52 pm #

    I think this topic will be discussed in the future, and personally I don’t think there is unified solution for this, since it is really from hospital to hospital.
    But in searching for the solution really all sides should be included in that process-patients,medical staff, government

    Anyway one thing would certainly help and that is better hospital management and internal organization…

  6. Southlake Homes Man July 13, 2012 at 9:35 pm #

    Big drug companies don’t help anything either. I was recently diagnosed with type 2 Diabetes. I got a free meter, the lancets (needles) are $10 for 200, but the test strips require Rx and cost about $2 per strip! That’s big drug companies at their best!

  7. Sam Apex August 16, 2012 at 10:17 am #

    The government shouldnt be cutting health care funds, if anything, they should be adding more funding to it in order to create more jobs such as home care jobs also the funding could create the opportunity to invest into the research of new equipment or medicine. Cost cuts will only make things worse.

    Sam Apex
    http://www.apexhsc.co.uk

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