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Lawrence M. Shuer
Chief of staff Waste Not! |
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Since virtually all of us who work in the health care industry are under considerable pressure to reduce costs, we are often frustrated by the forces that seem to work against our best intentions - reductions or other changes in reimbursement, government supplements, and contracts.We have at least two choices: We can sit around and complain, or we can take steps to deal with the forces around us. I submit that we must lobby people with influence whenever possible to make the case that we cannot survive unless this downward spiral of reimbursement is halted. At the moment, our institution is not recovering our costs of care, and if this trend continues, we will not be able to pay our bills. This is not a theoretical accounting issue: It's a very real survival problem. We also must stop blaming the merger for our woes. As separate organizations, UCSF and Stanford can be played against each other by third-party payers. I believe that together, as UCSF Stanford Health Care, we have negotiating strength and a united presence, which our contracting people can use to their advantage in forging reimbursement agreements that will allow us to meet the cost of care. Concurrently, we must continue to work to improve our competitiveness by reducing the costs of the care we deliver. Many years of operations improvement exercises have removed a lot of excess from the system. Now, the greatest opportunity for cost reduction is in physician practice. As physicians, many decisions we make about patient care could make large differences in cost with no impact on outcome. One of the best examples of this has been in our choice of medications for patients. How many times do we prescribe a latest generation antibiotic for an infection when one of the old-line, less costly drugs would work just fine? Sara White, director of pharmacy services at Stanford, has been leading the effort to educate the medical staff on the costs associated with these choices. Her department recently distributed a handout that documented the comparison costs of various intravenous fluids utilized for volume expansion. Clearly albumen is quite costly, and as it turns out, somewhat scarce. If normal saline, or even hespan or low molecular weight dextran, will work as well for patients, it makes sense to use those less costly fluids. We might also reduce our pharmacy costs by improving our use of sedation medication in the ORs or ICUs. Some of these medications, such as Propofol and Medazolam, are quite costly. Norm Rizk, professor of medicine and medical director of the intensive care units, has identified several situations where less costly medications could be substituted with a similar effect. As physicians we need to become more aware of alternative treatments that could save money. It is important to justify in our own minds whether there is truly an added benefit that justifies increased cost. The burden of proof is on us, not the budget-minded administrators who ask the questions they've been paid to ask. We also have opportunities in our practice to consider whether we could use labs and X-rays more effectively and less expensively. When we order the wrong test, another test may be required to establish or rule out a proposed diagnosis. This may happen most often when residents order a test without input from the attending physician, who might order a more appropriate test after his or her rounds. I suspect that we could reduce costs by reducing these "unnecessary tests" instigated in the name of teaching. Until now, we have allowed many of our trainees to learn by doing. We give them the freedom to act, then supervise them retrospectively during teaching "rounds." This traditional approach has worked pedagogically, but I think the reality is that we and society can no longer afford the economic costs involved with this type of training. The time has come for us to become more cost-conscious in our teaching. This in itself will be a lesson to our students and residents about how to practice the cost-effective medicine they will be compelled to provide. I am not advocating denial of needed care or tests to our patients. I am suggesting that we act wisely and efficiently in ordering medicines and tests. I also believe that our patients require some education. We must help them understand why we don't just bow to their requests to have expensive tests just to ease their minds when either we don't feel their symptoms or signs justify the tests, or we believe nothing in their care would be changed based on their results. Additional cost reductions could be obtained by standardizing equipment and implants where possible. For example in my field, perhaps all the neurosurgeons in the organization's four hospitals could agree on what types of surgical implants we should use. If we decide, say, upon one manufacturer for our ventriculo-peritoneal shunts we could cut costs by being able to negotiate a better price based upon volume and reduce the need to maintain supplies of other shunt hardware in our inventory. Another great potential for cost reduction in physician practice can be found in critical pathways or care plans. We have developed such plans for some of our very common disease categories at Stanford. By agreeing on which drugs, tests and therapies we will typically use for a given diagnosis, we have been able to make patient care more efficient and achieve reductions in length of stay. An example of this is in our anterior cervical disc removal and fusion pathway. We have developed a standardized plan of care for these patients that not only gives guidance to the attendings, residents, interns, students and nurses but also gives the patients an idea of what to expect. These pathways are not followed to the letter in every case as there are exceptions and variances. However, most of the time, the pathways are followed fairly well and allow us to evaluate our care over time so that changes in the plan can be made as needed. Certainly we as an academic medical center must not only look for new treatments and technologies, we must also find ways to teach our trainees to practice cost-effective care so that patients can receive the affordable health care the public is demanding. |
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