Quality over cost: New book focuses on physicians' role in improving value


“Understanding Value-Based Healthcare,” a book published in April, examines the exorbitant costs of the health care system—and how to correct the imbalance. Authors Christopher Moriates, MD, ACP Member; Vineet Arora, MD, FACP; and Neel Shah, MD, MPP, are each involved with Costs of Care, an organization championing medical cost containment. The nonprofit group was founded by executive director Dr. Shah, and Drs. Arora and Moriates serve as education director and implementation director, respectively.

Dr. Moriates works as an assistant clinical professor in the division of hospital medicine at the University of California, San Francisco (UCSF); Dr. Arora is assistant dean for scholarship and discovery at the University of Chicago; and Dr. Shah is an assistant professor of obstetrics and gynecology at Beth Israel Deaconess Medical Center in Boston. The authors spoke with ACP Hospitalist about their new book, noting that they believe hospitalists are on the “cutting edge” of improving value and could benefit from the tools therein.

Q: How did you become interested in health care cost and value?

A: Dr. Moriates: I actually became interested [in 2010] when I was a resident here in internal medicine at UCSF. Although I never had an interest in cost or any background in finance or business, what drove me crazy were all the things that I saw that we did for no reason—all the head CTs that my attending would ask me to get for people that I didn't think were necessary and all the waste.

Dr. Arora: I first became interested really [in the last 5 years] because it was something that a lot of our students and residents were asking about, and there were no good resources for them to learn about it.

Dr. Shah: It wasn't until I became a third-year medical student [in 2006], where they suddenly let you put on a white coat and touch real patients, that I realized that costs were an issue for my patients. And even though the faculty around me seemed omniscient when it came to everything else, the one thing that they had very little insight into was how our decisions were impacting what our patients were paying for care.

Q: What's the most interesting or shocking fact you learned while working on this book?

A: Dr. Moriates: It was really surprising to us, in some ways, that these issues that have existed for a very long time had not really been written about in a comprehensive way. This is not the first book ever on value or health care financing or health policy, but … I think it's pretty clear that clinicians, physicians, and nurses really haven't had a resource to learn this type of material in one place before.

Dr. Shah: What our book tries to highlight is that it's really a bell curve. The harms that happen in the delivery system happen from doing too little, and they also happen from doing too much.

Dr. Arora: I think one of the most shocking things is that although health care costs are rising exponentially, many physicians actually believe other groups should take primary responsibility for lowering costs. It just kind of goes to show you that raising awareness is part of the problem because, if you have a group that doesn't know how to start and don't see themselves as part of the solution, then how is it that we would ever solve the problem?

Q: For whom did you write this book?

A: Dr. Moriates: We wrote this book for health professionals, really for anybody training to become a health professional, as well as practicing clinicians.

Dr. Arora: We also try to keep in mind health system leaders and other directors, people who are in leadership positions in health administration who have the ability to perhaps implement some of these changes.

Q: What kind of feedback have you gotten so far?

A: Dr. Shah: Fortunately, it's all been positive. The biggest surprise for me, and part of what's really exciting, is the health system leadership being really interested in this.

Q: What are some ways in which clinicians can offer the best possible patient care while reducing unnecessary costs to the health care system?

A: Dr. Shah: It's not a matter of learning health policy or even knowing the dollars and cents of individual tests that we order; it's a matter of having strategies or taking the knowledge we already have and then surmounting the barriers of the good care that we want to be able to provide. For example, a lot of unnecessary care comes from trying to decrease our workload. Like, why get 1 test, wait for the result, and then get another when you can get 5 at once and then not have to think about it again?

Dr. Arora: Value equals quality over cost. And so, one way that you can improve value of care is to improve the quality of the care. The other way that you can do it is to think about items that have low quality, that really don't advance quality of care. It doesn't matter how much they cost, because the quality is 0. And then the other part of it is looking at cheaper alternatives that are equally efficacious, and so that would get at the bottom half of the equation. Here's a great example: In a patient on continuous nebulizers in the hospital for chronic obstructive pulmonary disease, there are studies that show that inhalers are equally effective after the first day.

Dr. Moriates: We also delve into how to engage patients in these discussions. We talk about shared decision making and empowered patients. We talk about high-value prescribing and what that means and how individual clinicians can work on providing the best prescriptions for patients. We talk about decisions around screening and testing, and finally, we discuss creating programs that clinicians are increasingly leading across the country to provide value improvement.

Q: What do you think the future might hold for high-value health care?

A: Dr. Shah: Billions of dollars are being invested right now in the Silicon Valley, all to make the Yelp for health care. [Such consumer rating systems are] just the reality of how medicine is and how it's going to be practiced going forward. Clinicians are going to have to own this, and even when things happen in the health care system that aren't necessarily our fault—like if you work in an expensive place, you might not be the one setting the prices—but you're the front door for the patient. You're their access point to the health care system, and so we need to figure out how we become better agents for them, and also how we can help them navigating all that complexity.

Dr. Moriates: What I expect to see is for people to continue to create tools and programs and to solve this problem in all layers of health care. I think that's the only way that this is eventually solved, which is that everybody is going to need to be chipping in from their perspective. This isn't a problem that can be fixed from the top down, nor is it really a problem that can be fixed from bottom up. It's got to be all of the above.

Dr. Arora: The future, I think, will be greater price transparency. So clinicians will have this information at point of care, whether it be through technology that makes it transparent—I know many people have been doing that in the electronic medical record—or mobile apps or other types of things. As price transparency goes live, we'll see more empowered patients.