Expert Consult

By Christopher Moriates, MD

Published September 14, 2016


“High-value care sometimes seems to be a problem for hospital leaders and policymakers. Why should individual residents be concerned with providing high-value care? Will it really matter if an intern orders fewer blood labs?”

This question was posed by Dr. Lakshman Swamy, Chief Medical Resident and VA Chief Resident in Quality and Patient Safety at Boston University in a recent NEJM Resident 360 discussion (Care, Cost, and Choice: How to Deliver High-Value Care). The discussion brought together medical students, residents, fellows, faculty, and national experts to explore the role of residents in the provision of high-value care.

The high-value care movement has gained traction over the last few years, becoming formalized in national policies and regulatory mandates. However, the practice of high-value care has penetrated variably across residency programs and academic centers. Consequently, residents are not always sure why they should care about practicing high-value care, how they can contribute, or even how to learn the fundamentals. The Resident360 discussion helped advance our thinking about the residents’ role in developing ways to ensure that we provide the best possible care — at lower cost — for patients.

What Do We Mean by High-Value Care?

The increasing cost of health care has inspired a focus on value, defined as quality of health care achieved per unit of cost.  The many definitions for high-value care focus on different aspects of the value equation, framed around differing viewpoints.

In a 2013 NEJM article, Dr. Lisa Rosenbaum stated: Value in healthcare depends on who is looking, where they look, and what they expect to see.

The American College of Physicians defines high-value care as health care that balances clinical benefit with costs and harms with the goal of improving patient outcomes. The Institute of Medicine defines it as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.”

However, there is general agreement that when high-value care is defined by patient-centered care, we can achieve the goal of delivering the best care for patients. That means focusing on patient-centered outcomes, including safety, experience, and affordability.

Why Should Residents Care About High-Value Care?

Residents are delivering care at the front lines, learning habits they will carry throughout their careers and training to be future leaders in health care. For this reason, focusing on high-value care is crucial for residents.

Simply put, we all have the responsibility of taking the best possible care of our patients. If we do not improve the system and focus on outcomes, then we will often fail. Value-based healthcare is about ensuring patients get the right care at the right time in the right setting. It also involves helping patients avoid unnecessary care, which can reduce harm caused by overtesting and overdiagnosis.

The front line clinician – resident – has a huge impact, noted Dr. Lauren Demosthenes, Medical Director of High Value Care and Innovation in the Department of Ob-Gyn at Greenville Health System in South Carolina. Residents write the orders and choose the products, services, [and] diagnostic tests for their patients. Patients have higher deductibles and copays, so cost matters to them. Society cares because the U.S. has healthcare costs that take away from other societal needs such as roads, schools, etc.

Another important reason why residents need to learn how to practice high-value care is the growing body of research suggesting that the environment in which you train has profound effects on future practices. In a health care environment where we are beginning to meaningfully tie payments to value-based healthcare, learning these skills is critical to a successful career.

Dr. Demosthenes added, It is exciting to see our residents embrace the opportunity to make a difference on the frontline now and participate in policy changes in our health system as we prepare for the transformation in healthcare.

Chief Resident Dr. Chris Worsham from Boston University agreed: Today’s housestaff are part of the first generation of physicians who are learning— starting in medical school — that value matters. For me this idea has been shaping the way I develop practice habits and attitudes since my first day of practice in residency.

Dr. Tony Breu, a physician in the VA Boston Healthcare System, added that decreasing overuse in the hospital directly helps residents’ own self-interest, in addition to that of their patients. Time may be the most precious commodity for housestaff. Every test/consult is a checkbox to be followed-up. Reducing the number of these checkboxes by minimizing low-value care will lead to more time for those things that do matter.

What Resources are Available for Trainees to Help Curb Overuse and Increase the Value of Care?

There are a growing number of resources that clinicians can use to help them provide high-value care:

  • Many high-quality guidelines inform care and define best practices (e.g., the American College of Radiology Appropriateness Criteria for guiding imaging decisions). Rather than ordering tests based on local culture, relying on guidelines gives students, residents, and clinicians a tangible rationale to choose to do (or not to do) a specific test. Reliance on evidence-based guidelines can inform discussions with supervisors, consultants, and patients about a recommended course of action.

  • The Choosing Wisely Campaign has become an international phenomenon, highlighting specific examples of overuse in medicine and explicitly tying this responsibility to physician professionalism. The website includes evidence-based recommendations of “things providers and patients should question” from more than 70 specialty societies. These lists are searchable by keyword, society, topic area, setting and other filters, providing a tremendous resource for identifying areas that are often considered low-value in many settings. The website also includes patient-friendly materials co-produced with Consumer Reports that help explain some of these topics.

  • The cost of prescription drugs is also important to incorporate into decision-making. Cost is one of the most common reasons that patients do not fill their prescription medications, and is a frequent source of patient non-compliance. With the increasing public awareness of some medication costs (e.g., the widely reported increase in Epi-Pen costs), more patients expect their physicians to know something about medication costs. Many clinical settings have integrated insurance formularies with tiers, and sometimes even patient-specific cost information, but that is not yet the norm in all clinics.

  • The Johns Hopkins High-Value Care group has put together a list of high-yield resources for teaching high-value care

  • Vineet Arora from the University of Chicago and colleagues published the following mnemonic to highlight strategies for lowering out-of-pocket costs:

GOTMeDS: Generics, Over-the-counter, Therapeutic Alternatives, Medication Review, Discount Drugs, and Splitting Pills

Good luck on your path to become excellent stewards of high-value care!

Christopher Moriates, MD
Christopher Moriates, MD is Assistant Dean for Healthcare Value and Associate Professor of Internal Medicine, Dell Medical School, The University of Texas, Austin.