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Cost-Effective Care: Can We Afford Not to Deliver?


The financial impact of health care on patients is not benign.

On a sunny, dry day this past February, I tripped on a crack in the pavement, extended both arms to cushion my fall and suffered a nondisplaced radial head fracture in my right arm, my first-ever fracture. 

After X-rays at the hospital, I made an appointment with an orthopedist, who presented me with a sling. He said I didn’t have to wear it but it might help me baby my elbow. I found the thing to be more cumbersome than comfortable, so I ditched it a couple of days later.

A few weeks later, I was surprised to receive an $80 bill for the sling from the company that supplied the orthopedist’s office. The doctor is in my network, so I had assumed my insurance would cover the sling. If I’d known it was going to cost me 80 bucks, I would have passed and asked my 16-year-old daughter, a certified emergency medical responder, to fashion me one from a scarf.

The thing is, my orthopedist probably had no idea how much my sling cost or whether my insurance would cover it, says Dr Christopher Moriates, a University of California, San Francisco, hospitalist who’s at the forefront of a movement to make doctors more sensitive to the financial impact of health care on patients.

While my doctor likely was well-intentioned, he should have at least warned me that I might have to pay out-of-pocket for the sling, says Moriates, lead author of “First, Do No (Financial) Harm,” a "Viewpoint" piece posted online July 8 by JAMA.

“To provide truly patient-centered care, physicians can live up to the mantra of ‘First, do no harm’ by not only caring for their patients’ health, but also for their financial well-being,” Moriates and his coauthors conclude.

As Moriates pointed out earlier this year in JAMA Internal Medicine, the Accreditation Council for Graduate Medical Education requires that residents “incorporate considerations of cost awareness” into practice. However, he and his coauthors write, medical education “has traditionally been silent” on this subject.

Thanks to Moriates, UCSF’s internal medicine residency program is silent no more. Starting in 2011, Moriates, a third-year resident at the time, designed and led a curriculum for internal medicine residents to promote cost awareness, improve attitudes toward cost control, and encourage the practice of cost-effective medicine.

“If we’re going to worry about prescribing the right medicine but then not worry about whether our patient can actually pay for the medicine and take it, then we’re not doing any good,” Moriates says.

While some doctors worry that increasing focus on the cost of care could end up shortchanging patients, Moriates says, “I think that’s very unlikely at this point.” He cites an Institute of Medicine report released last September that concluded 30% of health care spending doesn’t make patients healthier, and about a third of that amount is spent on unnecessary services.

“When I was a medical student [at Brown] . . . I was specifically taught not to think about costs,” says Dr Neel Shah, one of Moriates’ coauthors on the JAMA "Viewpoint" piece. “If you’re thinking about costs, you might not do everything possible for your patient.”

By his third year, when he first became directly involved in patient care, he became so disillusioned that he left medical school. “I really didn’t understand why we were doing a lot of the things we were doing,” Shah explains.

In search of answers, Shah earned a master’s degree in public policy from Harvard’s Kennedy School of Government before returning to medical school. In 2009, while an OBGYN resident at the Brigham & Women’s Hospital and Massachusetts General Hospital, he founded a nonprofit called Costs of Care, for which he now serves as executive director. The group’s mission is to empower patients and their caregivers to deflate medical bills.

One way to do that is to make cost information more accessible, Shah says, noting that more than 20 states are considering or have already enacted legislation to improve the transparency of health care costs.

“We live in an era where most of our purchasing decisions are based on transparent cost information,” Shah says, citing Web sites such as Yelp!. “If we can do it for restaurants, there’s kind of an expectation that we can do it for health care.”


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