Cost Awareness and Fellowship Education

“Price is what you pay; value is what you get.” –Warren Buffet

Costs related to care of cardiovascular disease have accounted for about 15% of the increase in medical spending in last decade, growing 6% annually, and are projected to cross $800 billion by 2030. New procedures and techniques including TAVR, controlled antegrade and retrograde subintimal tracking (CART), and Impella (Abiomed) have enabled treatment for patients who previously had no other options. The question remains, however, with the healthcare budget bursting at the seams, how will the increase in costs related to improvements in care be covered?

In recognition of these issues, the Accreditation Council of Graduate Medical Education (ACGME) made systems-based practice one of the six core competencies that need to be acquired during residency and fellowship training. Other than optimizing resource utilization, one of the key tenets of this competency is cost awareness, which unfortunately is still underemphasized during residency training. A survey of 2014 graduating residents from Yale-New Haven Hospital found that while 95% felt cost containment is the responsibility of every clinician and half agreed that cost influenced their ordering decisions, only 4% stated that they actually know the costs of care.

When physicians know the costs of healthcare services, equipment, and pharmaceuticals, they are able to make informed decisions on the cost and effectiveness of diagnostic and treatment alternatives. Also, this knowledge creates transparency within the medical community regarding the affordability of treatment options for patients, which is now a major concern. The difference in price among various catheters, wires, and devices is a variable that can be controlled to increase the cost-efficiency of procedure if the cheaper equipment accomplishes similar results. Smaller differences in costs over time can have a large effect on the cath lab budget. Recently there has been a significant movement to switch from a fee-for-service model to bundled payments with both accountable care organizations as well as the Medicare Access and CHIP Reauthorization Act (MACRA), although this potentially might not happen. Regardless, with regulatory changes coming at us, costs are increasing and resources are consistently limited, so there is an urgent need to educate future cardiologists during fellowship itself about cost of care.

Given the substantial variation in cardiology practice patterns across the country, multiple factors could be modified in order to optimize resource utilization and provide high value care. Several strategies have been tried over the last two decades to increase cost awareness in physicians and to assess impact of these interventions.

The simplest strategy, in my opinion, is encouraging the attending physician to discuss relative costs of diagnostic and therapeutic interventions with all members of the care team. Others include providing list prices or integrating prices with electronic health records, which have both shown to significantly reduce costs as well as frequency of tests ordered during and after intervention. Innovative approaches have also been adopted in some pioneering residency programs that can serve as template for introducing cost awareness education into fellowship. For example, Yale-New Haven Hospital has implemented what they call an interactive cost-awareness resident exercise (I-CARE) that consists of case review with actual hospital charges during morning report, providing instruction in cost-effective care.

American College of Cardiology/American Heart Association (ACC/AHA) guidelines have until now considered only what is best for the individual patient without discussing costs to society. Guidelines committees have recognized that cost considerations ought to be made more transparent and that the evidence on economic value should be explicitly cited when available. These concerns were formalized by a recent white paper, and there are expectations of inclusion of value in future guidelines. In the interim, different interventions can be compared using Institute of Clinical and Economic Review (ICER) reports as well as National Institute of Health and Care Excellence (NICE) guidelines from the United Kingdom, which have included cost-effectiveness analyses to compare interventions by quality-adjusted life-year gained.

Providing high-value care is a responsibility of every healthcare practitioner as we are the stewards of patient care. Cost considerations and extent of benefit should be key components during all clinical decision-making. The objective is not to ration care, but to achieve best outcomes for every dollar spent for each patient and as a society.