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Viewpoint: Why Cost Must Be Part of Our Education

Mosley, Mark MD, MPH

doi: 10.1097/01.EEM.0000410883.18751.9d
Viewpoint
Dr. Mosley

Dr. Mosley

Our government faces a catastrophic debt, a good portion of it paid out in Medicare and Medicaid. We can no longer afford to practice medicine this way, with these programs our safety net for the elderly and poor.

At the heart of this reality are the costs (and charges) of our health care system. Cost has not traditionally been part of our training, and most physicians have not felt empowered to affect it. We must begin to change this, especially in emergency medicine.

The ED is strongly representative of our Medicare, Medicaid, and uninsured populations. Keeping them from going to the ED is untenable so we must address ED cost issues in these populations.

Evidence-based medicine should not exist in a vacuum. It is wrong-headed to use only the best test to prescribe the best medicine to get the best possible outcome. We need economics to strive for pragmatic medicine. (N Engl J Med 2011;364[18]:1685.) Every medical outcome comes at a cost, the balance of which is called value. We cannot know the value of our science if we cannot discuss how cost equates to outcome.

When medical professionals talk in a common scientific language about the value of medical tests, pharmaceuticals, operations, and therapies, we are enlightened about the lack of or only marginal value of medicine. When patients and the media pick up this information, we change patient expectations, and begin to embrace a philosophy that less medicine is cheaper and often just as good or better.

For some of us, particularly those in training or new to practice, the economics of our health care system may be foreign. We all need a current map.

  • We have the most expensive health care in the world, but our health is not better.
  • No matter which party is in control, the United States cannot afford our health care system.
  • Experts point to cost containment, but current political strategies simply cost-shift away from government payments. Private insurers are expected to pay more with physicians paid less.
  • The government is employing strategies for safety, quality, and efficiency, but these strategies are about the government saving money. These go by “meaningful use,” “quality metrics,” and “pay-for-performance,” but almost no data suggest that these are safer, faster, or cheaper.
  • It is simply assumed that medicine should continue to be expensive because of newer technology, an older population, and the complexities of the end of life, which cost a disproportionate amount of money.

Those who ultimately control costs are the physicians who do surgeries, write prescriptions, and order tests and therapies. For us as medical professionals to begin to control costs, we must know the costs and charges of medicine. Our students, residents, and their attending physicians must learn cost with the same vigor they learn physiology. Consider that omnicef is generic, but still costs more than $80 while amoxicillin is on the $4 list. Or that ciprofloxin otic is about $100 while ciprofloxin ophthalmic (which can be used in the ear) is about $10. Or that a box of Xopenex vials is $360 while a box of albuterol vials is $35, and most proton pump inhibitors cost $100-$150 a month. A comprehensive metabolic is $30 more than a basic metabolic (in our facility), and Cleocin and Metrogel cost about $35 each, but oral metronidazole is on the $4 list. An H&H is around $140 while a single Hgb is only $70.

Five to six percent of the general population is noncompliant due to cost. (Clin Ther 2004;26[4]:607.) I'll bet it is 10 to 20 percent in the ED.

Only one of four people who can't afford medication discussed it with his doctor. (Arch Intern Med 2004;164[16]:1723.) It should be an automatic question to every patient: “If I write you a prescription for a medication, will there be any difficulty in getting it filled?” And when they say, “I don't know. How much does it cost?” we must know the cost, and negotiate whether a “cheaper-almost-as-good medicine” can be used. This is not just for noninsured patients; there are now many patients even with excellent insurance who opt not to have pharmaceutical coverage to keep their monthly payments lower. Recent studies have shown that when physicians know the costs (charges) of the lab tests they order, they order fewer tests. (http://bit.ly/ACEPNewsCosts.)

We need to change the way we talk about our statistical outcomes with each other and our patients. We need a common language that translates outcomes into cost. This begins by largely ignoring p values and statistical significance as awkward and often inaccurate. We should largely ignore combined endpoints, post-hoc and subgroup analysis, surrogate marker outcomes, and outcomes reported as percentages as insufficient and potentially deceptive.

We then adopt a common statistical language that, while far from perfect, allows us to discuss potential benefit, potential harm, those unaffected by treatment, and cost as a foundation that cements every outcome. We already have this language. It is called number needed to treat (NNT).

We have good data, for example, to show that taking an aspirin each day for prevention in a population at low risk for heart attack will benefit one of approximately 1,200 patients in the general population under 80, will harm one of 833 patients with major GI bleed, will harm one of 247 patients with any bleeding, and will not benefit or harm about 1,194 of 1,200 patients.

If we look at high-risk individuals for heart attack and GI bleeding, aspirin will benefit one of 100 patients, will harm one of 133 patients, and will not benefit or harm 98 patients out of 100.

Even if this language is only a ballpark estimate, it allows us to talk about the magnitude of benefit and harm that most people can understand. With aspirin, the cost is negligible.

A child comes to the ED with head trauma and a GCS of 15. Does he need a CT scan to rule out intracranial hemorrhage? The number needed to benefit is one of 1,000 will have unsuspected ICH requiring neurosurgery. (Lancet 2009;374[9696]:1160.) The number needed to harm is one of 1,000 children getting a CT scan may ultimately develop thyroid or other cancer. (Pediatr Radiol 2002;32[4]:228.) The number with a neutral outcome is 998 children out of 1,000, and the average “cost” (charge) of a CT scan of the head, very conservatively, is $1000.

These numbers are easily understood in risk and cost. We could potentially charge $1,000,000 or more to find one ICH while causing cancer in one patient to find it. Some may argue with the numbers, but it is about creating a common statistical language that includes benefit, harm, neutral outcome, and cost to achieve outcomes.

Once we in the ED and medical community develop a common language of value, we can practice better and share a philosophy that less medicine is cheaper and may be better. We must accept the fact that one-third of the medicine we do is unnecessary, not to mention that other therapies are neutral or only marginally helpful. (“More Medicine Is Not Better Medicine.” New York Times. Dec. 1, 2003; http://nyti.ms/MoreMedicine.)

Considering the mass volume of all the medical journal articles, the most astonishing conclusion is how scarce well done science with meaningful clinical conclusions for relatively common diseases is. If we ask only for measure of harm as the other side of benefit, this slice of information becomes a thin sliver. (BMC Med Res Methodol 2009;9:21.)

Professional integrity erodes when advertising tries to hold hands with scientific education; marketing and medicine create adulterous relationships. Pharmaceutical and medical device companies and even national medical organizations do not want physicians to know the relative value (or non-value) of a new expensive medicine or device.

How many of us know that the makers of Neurontin were convicted of criminal fraud for pushing physicians to prescribe the drug for chronic pain, for which it does not have FDA approval? (Our Daily Meds: How the Pharmaceutical Companies Transformed Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs. New York: Picador; 2008; N Engl J Med 2009;360[2]:103.)

Or that the makers of Celebrex, the most successful drug in U.S. history, falsified its study? The true conclusion, billions of dollars later, was that Celebrex has never been shown to be more effective or safer than ibuprofen. (The Big Fix: How the Pharmaceutical Industry Rips Off American Consumers. New York: Perseus Books Group; 2003.)

That Lipitor has never been shown to be helpful for women? (Arch Intern Med 2006;166[21]:2307.) That six of the eight members of the American Heart Association panel that recommended IV tPA for stroke were paid consultants of Genentech, which makes IV tPA? (BMJ 2002;324[7339]:723.) That eight of the nine members of the American Heart Association panel that changed the definition of hypercholesterolemia and tripled the amount of patients who might qualify for statins were paid consultants of statin companies? (Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.)

It is tragic and damning that in an era of better science with better designed studies and better ways to share findings that the information is less trustworthy because of financial conflicts of interest. Declaring these conflicts of interest has been a thin and ineffective veil. Physicians with severe conflicts of interest often just lie.

We have our own ethical struggles. Many of us know we are hedging, if not making up stuff, when we tell patients they have “a touch of pneumonia” or an “early sinus infection.”What makes us write a prescription for Zithromax or Zofran? Primarily fear.

Everyone in medicine chants that lawsuits make us practice unnecessary medicine. No question, tort reform is critical to control medical costs. But it is not clear, even if tort reform were enacted tomorrow, that our fear of being sued and the behaviors that follow would be any different. The boogeyman does not need to be real to make you sleep less.

“Fear of being sued,” I'm afraid, often means “fear of being wrong” or “fear of the patient not liking me” or “fear of losing business.” These are not the lawyers' fault; they are our failure to communicate the truth. While we need tort reform tomorrow, we could use a stiff dose of scientific integrity and moral courage today.

Cost is a necessary and critical variable to any good or service. Our government can no longer financially tolerate the medical profession's neglect of this fact. Physicians must ultimately control cost, and we must educate ourselves on costs (and charges) in residency. Pharmacists partnering with physicians can be an essential step in gathering and disseminating this information.

Cost combined with a common statistical language (number needed to treat, etc.) leads us closer to discovering the value of tests, medicine, operations, and therapies. The conversation of value will lead us to understand that much of what we do has little or no value. This is information that we and our patients need.

The difficulty of getting untainted scientific information can be helped by groups like the Cochrane Collaboration, which intend to have no conflict of interest. The ideal scenario would be for local medical societies to have multispecialty input with no conflict of interest to create local “best practice” with attention to cost. This would also potentially provide legal protection.

The fear of patients not accepting a minimalist therapeutic approach at a cheaper price for lower acuity situations must be girded with the reality that shared decision-making with the patient provides greater legal protection, greater patient satisfaction, and greater efficiency than ordering more, prescribing more, and doing more. With good communication that carefully acknowledges cost, the magnitude of benefit and the magnitude of harm, we find that psychologically healthy patients make decisions that physicians wish; they have no desire to spend hundreds on a therapy that has little benefit and possible harm.

If a patient does not like that you have the scientific integrity and courage to say, I don't know of anything that will make a significant difference in your illness,” it's better to let them go where they pass out prescriptions and do tests with abandon. Those places will not last long. Anyone can do too much (and cheaper than a physician), but it takes real knowledge to know you can do less.

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