Increasingly, physicians are speaking out against wasteful spending on needless medical treatments. At her South Carolina hospital, Lauren Demosthenes, MD, is targeting "low hanging fruit that doesn't hurt the patient or the doctor."
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There seems to be no shortage of tales about wasted dollars in healthcare.
Last week, I wrote about a $20 test that became a poster child for needless, yet costly hospital treatments as explained by a San Francisco physician crusading to change healthcare's profligate spending habit.
This week another proponent of wiser spending, OB/GYN Lauren Demosthenes, MD, gives examples of wasteful care practices embedded in the obstetric suites of Greenville Memorial Hospital in South Carolina, and probably at most other hospitals across the country.
Take Cervidil, a product that hastens cervical dilation in women whose labor is about to be induced. Greenville Memorial charged $810 for a drug it bought for $354.42.
A pill called Cytotec, for which the hospital charged $4.20 and paid $2.28, does the job just as well, Demosthenes says.
Then there's Epifoam, a topical anesthetic to reduce inflammation and pain from stitches after an episiotomy or laceration during delivery. Greenville routinely gave Epifoam to about 222 women per month after birth, and charged $154.40 for this product, which it bought for $44.06. Yet a simple icepack and pain relievers like ibuprofen would get the job done just the same, Demosthenes says.
At 710-bed Greenville Memorial, "There was no other reason people used that (Epifoam) other than the fact that it was on the standing order, and nobody looked at how much it would cost," Demosthenes says. Even new mothers who didn't get stitches got Epifoam, a charge ultimately passed on charges to payers, she says.
After getting agreement that Epifoam wasn't a must-have expense, Demothenes successfully argued to "have it unchecked from standing orders, and we went from 222 Epifoam orders a month down to 18." She projects that the hospital's annual costs for the product will drop from $117,375 to $8,459, and charges, reflected in bills to payers, will drop from $411,321 to $33,350.
For reducing the use of Cervidil, the hospital is pushing for voluntary behavior change among physicians with expected costs to the hospital dropping from $118.433 to $51,036.
"This is low hanging fruit that doesn't hurt the patient or the doctor. It's a little thing, not all that much money. But if you could find five little things to save in your system without decreasing value, that's doing the right thing."
Demosthenes is part of a tiny but growing minority of providers who now consider cost and value when deciding how to treat patients and want their colleagues to start thinking more about it too.
And although her concerns are starting to be heard, she says, often, "when I present the information I have, people just look at me, maybe not like I'm crazy, but they ask, 'Why do you care about this? Insurance pays for it. This is how the hospital makes money.'
"I know, but that's still not the right thing to do. We should be good stewards of our healthcare dollars," she says. "Doctors want to do the right thing. They just have these habits, and aren't aware of the costs."
Demosthenes, a blogger and supporter of the Cost of Care project, a non-profit seeking to empower patients and caregivers to "deflate their medical bills," last fall tried to gauge whether the healthcare reform law's goals to reduce cost and improve quality was a message that was getting through to providers.
So she surveyed 88 residents, faculty, community physicians, and midwives on staff at the six-hospital Greenville Health System network. Of the 50 who responded, 75% underestimated costs of caring for two hypothetical patients, she says.
For example, only 4% correctly guessed what her hospital paid for Epifoam, and only 2% knew the cost of Cervidil.
In case one isn't convinced that a lot of hospital procedures have no logical rationale for a lot of order sets and procedures, some of which may even cause harm, Demosthenes has a few others that persist in her specialty of obstetrics and gynecology.
One is repeat testing in pregnant women for the inherited blood disorder sickle-cell anemia. If a woman tests negative for it one time, she doesn't need to be tested again during subsequent pregnancies. "But we just repeat the test. Why? Because it's too much effort to find the old test."
Pap smears are performed more frequently than the once-every-three year recommended interval as well, she adds. Done too frequently, they may provoke clinically irrelevant findings of things that are unlikely to be cancer, or are so very slow growing as to be meaningless. Yet pap smear tests done too frequently can lead to biopsies, which are uncomfortable, add cost, and "may lead you to have a procedure that could go wrong."
And ultrasounds, which are expensive too, are done too frequently, often in pregnant women who just want another picture, she says.
Demosthenes acknowledges a huge dilemma that doctors like her face every day. They're increasingly being scored, and paid, on the basis of patient experience scores.
"So rather than talk to a patient about why they don't need a test, and not having them get one and risk having them be dissatisfied," a doctor feels pressure to allow it. "You don't want to make the patient angry." Reducing costs and unnecessarily harmful utilization, she says, "are incentives that are not consistent with each other."
A few increasingly vocal doctors are crying out across the country to get their peers to pay attention to even these silly little things. At this rate, I'll have another few examples from other specialties in my e-mail in the next few days.
Demosthenes isn't talking about cutting a billion dollars from her hospital's costs. But as she says, these early efforts are "low hanging fruit." And having a baby is one of the biggest, if not the biggest, reason for hospital admission.
A few swipes at the cost curve here, and a few swipes there. We might just start talking about real money.