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Laura Schmidt, PhD, delivers a lecture on health reform history to a standing-room only classroom. This presentation is part of the "Affordable Care Act and the Future of Healthcare Reform" course.
Photo: Susan Merrell
By Mitzi Baker
A surefire way to lose the attention of medical students and trainees is to give them an overload of dire statistics about national healthcare costs.
Christopher Moriates, MD, assistant professor of medicine, has an easy solution. “When we tie these ideas to how important cost is to the patients in front of them and how that fits in to the role of healthcare provider, we win them over,” he says.
Moriates is part of a growing effort to promote “value-based healthcare” at UC San Francisco and other healthcare centers nationwide. Defining “value” is difficult; Moriates devoted an entire chapter to the word’s definition in his co-authored 2015 textbook Understanding Value-Based Healthcare for medical educators and clinicians. However, there is general agreement that value entails improving quality, outcomes and the overall patient experience while simultaneously decreasing the cost of care.
“With value-based healthcare, we think about ‘harm,’ which includes harm that comes from patients or society having to spend too much money on healthcare,” says R. Adams Dudley, MD, MBA, professor of medicine and health policy. “People are losing their homes because of care they might not have needed.”
Medical costs have been reported to be at the root of 62 percent of personal bankruptcies and more than 75 percent of those going bankrupt due to medical expenses had insurance.
“To ‘do no harm’ is not a new concept, but what is new is that we are making choices that are also economically more sound,” says George Sawaya, MD, professor of obstetrics, gynecology and reproductive sciences. “This idea fits with our observation that medical care is very expensive, and, most people think, unsustainable at the current rate of expansion.”
The United States spent $2.9 trillion on health care in 2013, which represents more than 17 percent of the national economy, according to the last figures released by the Centers for Medicare and Medicaid Services.
“The idea of value speaks to finding a solution to why we not only have the most expensive healthcare system in the world, but at the same time we don’t have the best healthcare system in the world,” says Sandrijn van Schaik, MD, PhD, associate professor of pediatrics.
Henry J. Kaiser Family Foundation statistics show that the United States spends at least 40 percent more on health care per person than Norway, the next highest per capita spender, while simultaneously having worse outcomes than comparable countries on most measures, including higher overall disease burden, higher infant mortality rates, more hospital admissions for preventable disease and higher rates of medical, drug and lab errors.
“The medical community has a responsibility to mitigate the expensive and ever rising costs of medicine by integrating value-based clinical decision making into the curriculum,” says Sawaya.
This change requires new teaching methods. “Teaching value is really just teaching ‘right’ care,” says Moriates. The goal is to marry what the evidence says should be done in a given situation with the downstream costs of testing and medical care, both financially and physically. “We have to start considering what the tradeoffs are for each decision we make,” he says.
An integral part of the new Bridges curriculum is learning about processes to analyze systems and make them better and safer for patients. The concept of “value-based decision-making” will be specifically called out earlier and woven throughout the four years of training.
“We want to make transparent to students that there are ways to approach patient care that is of high value—getting the right diagnosis—but also thoughtful enough to minimize the costs, mainly in terms of testing,” says Sawaya. Medical students will learn about specific opportunities to make informed choices and how to initiate opportunities for their teams to eliminate overuse.
Moriates has pioneered cost awareness curricula for internal medicine trainees and is bringing this expertise to medical students through Bridges. He and others present diagnostic workups of patients with specific conditions (such as a pulmonary embolism) and demonstrate the different diagnostic strategies and their associated costs. Hospital bills of actual patients help open learners’ eyes to the amount of money spent and encourage brainstorming about ways to cut costs.
To ensure that UCSF faculty understand the concepts of value-based healthcare and are able to teach its principles and be role models for competencies in practice requires some training. “We want to get as many educators as possible on the same page and give them the knowledge and skills about how to teach all of this,” says van Schaik, who is the faculty development lead for Bridges.
At van Schaik’s invitation, members of the American Association of Medical Colleges (AAMC) presented a day-and-a-half faculty development workshop in January called “Teaching for Quality,” which trains clinical faculty to effectively teach quality improvement and patient safety to medical students, residents and other clinicians.
All 34 UCSF participants have embarked upon yearlong group educational projects that span the entire breadth of teaching activities. One project targets faculty working directly with medical students in the longitudinal workplace learning environment established by Bridges. will help educators design effective systems-oriented workplace learning experiences for first- and second-year medical students; this includes selecting appropriate activities and teaching techniques for early learners and implementing feedback mechanisms for students and staff. Other projects address resident and fellow education; one aims to create an overarching structure that helps faculty to identify and choose from available resources, programs and pathways with the goal of establishing a cadre of faculty developers who will ensure sustainable training of future educators on quality and value.
Christopher Moriates, MD, is a pioneer in cost awareness curricula.
Photo: Choosing Wisely website
“What is exciting is that we are moving from talking and teaching about value to actually empowering the learners themselves to be the change agents,” says Moriates. “This is truly education turning into action.”
Medical students will have ample opportunity to use their new skills of value-based healthcare in their teams in the workplace. “If we ever want to get to the best possible value, part of what we must value is the other staff on the team, as they may observe things that medical students or doctors miss,” says Dudley. “Good ideas come from everyone.”
Ultimately, the goal is to go beyond simply acquiring the skills of thinking about value and discussing it with team members and patients. “We want to change attitudes,” says Dudley. “We want to create a new population of physicians who say: ‘I need to stamp out waste, low value and unnecessary financial burdens just as much as I need to stamp out streptococcus and cancer… if I don’t do that, a lot of harm comes to a lot of people, therefore I look for opportunities to do it and I am excited to do it.’”