The push for clinicians to talk more about health costs

When a patient's information is entered into Cedars-Sinai Medical Center's electronic health records system, an alert pops up if a planned procedure or test is listed as unnecessary based on current evidence.

These prompts saved the L.A.-based system $6 million in avoided healthcare costs in the first year of implementation.

Dr. Scott Weingarten, Cedars' chief clinical transformation officer has said the initiative empowers those responsible for delivering bedside care.

But many health professionals remain unaware of the cost of the care they deliver, according to a study published this week in the Journal of the American Osteopathic Association. A survey of more than 400 emergency medicine professionals found that only 38% of them could accurately estimate the cost of treating three common conditions in an ER.

As hospitals begin to control costs more consciously in a value-based environment, they are asking staffers to be more frugal.

"There's a paradigm shift that's happening across the country in terms of cost of care," said Dr. Jay Bhatt, chief medical officer for the American Hospital Association, adding that clinicians are taking an increasingly active role in fiscal responsibility—mostly as a result of uncertainties in the industry. Many providers are preparing for the 2019 implementation of the Medicare Access and CHIP Reauthorization Act. They may once again have to take on the sole responsibility of medical costs for the 24 million people who gained coverage through Affordable Care Act provisions and could lose it via the American Health Care Act. Providers are required under federal law to subsidize some healthcare services.

Frontline staffers are key to keeping costs down. More than 80% of overall healthcare expenses result from patient-care decisions, according to a 2016 study published in the Texas Heart Institute Journal.

While patients in high deductible plans could especially benefit from more frugal clinical decisions, advocates worry clinicians will prioritize cost-saving over a patients' wellbeing.

"You shouldn't bring cost as a reason to the bedside but you can absolutely get involved and should with price discussions in other settings, like the formulary committee, or with insurance companies, or even politically," said Arthur Caplan, head of the bioethics division at NYU Langone Medical Center.

Clinicians may also consider costs to patients because medical debt has been deemed a social determinant of health by public health officials. Leading physician specialty organizations are asking members to find more economical alternatives to treatments and to discuss those options with patients.

"A major and unmeasured side effect of the care that we deliver is the financial harm that we do to patients," said Dr. Cynthia Smith, vice president of clinical programs for the American College of Physicians. Smith said ACP is developing curriculum to help physicians have conversations with patients about the cost of treatment.

It's also about reestablishing relationships, she said.

"The time is ripe to really figure out how to efficiently and effectively broach these conversations in the examination room so that trust is reinforced (between doctor and patient)" Smith said.

Delivery systems have been thinking about cost-cycle management in addition to revenue cycle management, according to Dr. Neel Shah, founder and executive director of Cost of Care, a not-for-profit organization that helps educate physicians on how medical decisions impact patients' medical costs.

"It's not about making cuts, it's about trying to get to a place where we're delivering care that's effective, safe, and ultimately affordable for people," Shah said.

Cedars isn't the only example of a system pushing the responsibility upon clinicians. The Center for Healthcare Value at the University of California, San Francisco holds an annual contest soliciting ideas on reducing inefficiencies from staff.

Two to three teams every year receive $50,000 prizes, and recent winners' ideas have led to decreases for target groups in blood transfusions, operating room supply costs, and antibiotic overuse in newborns, according to the center's website.

ABIM Foundation's Choosing Wisely national campaign, which aims to reduce unnecessary medical prodedures, aids the Center for Healthcare Value's and Cedars' initiatives.

Dr. Reshma Gupta, evaluation and outreach director for Cost of Care, said clinicians need to talk more with patients up front about the cost related to their care in the same manner as other professions, and arguments against that practice ring hollow at a time when medical bills and out-of-pocket health spending can often cause patients harm when they delay or forgo seeking treatment due to cost concerns.

"I think the majority of patients by far want these conversations," Gupta said.