Elimination of routine testing. Hospital staff ask physicians to individually order blood tests only when they're needed, instead of ordering all 20 in an order set. Early estimates are that these efforts have reduced overall lab testing by 6%.
Adler acknowledges that making many of these changes wasn't easy. Pushback from senior physicians had to be overcome. "They'd say things like, 'I believe IV administration is better.' But in many cases we showed compelling scientific evidence that it wasn't. And that proved pretty convincing."
Financial harm and patient harm
In Boston, one of the leaders of this physician cost and quality movement is Neel Shah, MD, 31, executive director of Costs of Care, a project he started in 2009 as he began his obstetrics residency at Brigham & Women's Hospital.
He did so when, during his OB rotation, "I couldn't understand why people were opening up a pair of gloves to do an exam, but only using one glove and throwing the other away," he says. "Then I found out that each glove was $5." He also saw different surgeons using different pieces of equipment for the same procedure, one costing $300 and the other $5,000, with no evidence the $5,000 one was better or necessary.
The idea behind Costs of Care, he says, was to gather similar stories from clinicians around the country about waste, high cost, and overuse. An underlying premise, he emphasizes, is that "financial harm is a very real form of patient harm, a basic quality issue," because it meant, for some people, choosing treatment might land them in bankruptcy or cause stress that exacerbates their underlying illness.
At first, he acknowledges, his ideas weren't very popular with his superiors.
"As a junior person, it was very hard not to be perceived as a whippersnapper when you're talking about how to make healthcare better. And there's extra sensitivity at an academic medical center where care is even more expensive" than at community hospitals.
But timing was everything: The start of the Obama administration and its healthcare focus, and the Costs of Care website and the story submissions from physicians and some patients exploded, giving Shah and the organization a national profile. "It was the first time we had a large cohort of physicians to step up and say, 'This is what we see every day.' "
Shah emphasizes that while cost is not something usually perceived as a quality issue, "it absolutely is one." For example, one of his projects is to reduce unnecessary C-sections.