Monday, February 27, 2012

What's in your health care shopping cart?

A few years ago, we received a letter from a physician reader who complained that the approximate prices of drugs provided in AFP were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of the rationale and process for estimating drug costs in the journal, as AFP editor Jay Siwek, MD explained in this January 2010 editorial:

Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.

Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:

What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.

The American Academy of Family Physicians has partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should family physicians' virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?

2 comments:

  1. The costs of medical care are completely out-of-hand - and continuing on exponential rise. Clearly, something must change if there is to be any hope of controlling costs at a less-than-exhorbitant level. Except for the totally rich - uninsured Americans are no more than a single major illness away from bankruptcy ... Providing specific information on the costs of drugs, medical tests and services is an important first step - and at least will help in the problem of unawareness by all-too-many clinicians of what actual costs both in- and out-of the hospital truly are. But it's only a first step. All-too-many of the costs are hidden - and unknown even to the lab or clinician office offering the service (ie, I find my self unable in most instances to get a dollar amount for the "bottom-line cost" for a test or service that includes all-the-extra-fees that are all-too-often embedded - and which trickle in as bills long after the procedure or test is done). Cost of drug to the pharmacy is often far different than cost of drug to the patient - and even if specific prices are listed, they may vary tremendously among pharmacies even within the same city ... So - YES - it IS good to begin listing as many costs as is feasible in places that will be viewed by practicing clinicians and medical staff - but there remains a LOT of work to be done if our goal is to realistically help control the spiraling costs of medical care - Ken Grauer, MD (2-27-2012)

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  2. Interesting post. The best book I have read in years, on health or anything, is Better. I was lucky enough to have a neigbor lend it to me otherwise I wouldn't have heard of it. http://caroleschatter.blogspot.co.nz/2011/11/better-by-atul-gawande.html

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