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Teaching High-Value Care to the Future Workforce

Niels D. Martin, MD, FACS, FCCM; Robert L. Ricca, Jr, MD, FACS, FAAP, CAPT, MC, USN; Hee Soo Jung, MD, FACS; Roshni Sreedharan, MD; Oveys Mansuri, MD, MBA, FACS

The United States has the highest healthcare expenditures per capita of any country in the world.1 Despite this, the United States lags behind other industrialized nations in some key healthcare metrics such as life expectancy and infant mortality.1 This disparity has fueled a focus on healthcare value. High-value healthcare can be defined as the ratio of the outcomes of the healthcare over the cost of the care provided. Cost can be variably defined as not only direct monetary expenditures but also by the loss of patient productivity in society (time away from work, childcare expenses, etc.).2

Introducing cost and thus value considerations into healthcare delivery has proven to be a formidable task in U.S. culture. Culture change initiatives have shifted to include a focus on the future providers, teaching value from the onset of medical education. Organizations such as the Accreditation Council for Graduate Medical Education (ACGME) now include an expectation to “advocate for quality patient care and optimal patient care systems.” However, the term value still escapes their common program requirements.3

The potential value added by the introduction of cost considerations in critical care is profound. A significant portion of hospital expenditures occur in the critical care setting. Thus the best value for healthcare educators is to focus on today’s future intensivists.

Teaching High-Value Care as Defined by Quality and Safety
Good-quality care and safe practices aim to decrease the occurrence of complications. Complications nearly uniformly lead to longer lengths of stay and increased utilization of resources, thereby increasing costs. Therefore, value can be boosted by mitigating harms.4 Beyond harms, quality improvement (QI) also centers on decreasing avoidable costs such as unnecessary services, inefficient delivery, and missed prevention opportunities.5 The Institute of Medicine reported that these issues accounted for costs of $395 billion in the United States in 2009.Specific to critical care, QI focuses can focus on areas such as reducing unnecessary laboratory testing (unnecessary services), coordinated post-intensive care clinics (inefficient delivery), and improving adherence of bundled care (missed prevention).

Trainee involvement in QI programs has the benefit of being learner driven, patient centered, and impacting institutional culture.4 These elements can bring significant meaning to clinicians’ practices as well. QI training should combine specific knowledge transmission, reflective practice, and a supportive environment.6 Trainees should be educated on evidence-based best practices, encouraged to examine the patient care in which they are involved (practice-based learning and improvement), and assigned to active roles in ICU QI programs. Based on their presence and attentive-learner status, critical care trainees are primed to help make important impacts on the delivery of high-value care.

Clinical Efficiency, Uniformity of Care, and Systems-Based Practice
The U.S. healthcare system is complex, with many stakeholders who have innumerable and often conflicting goals. This has allowed for widely disparate practice patterns between not only institutions but also individual providers. Variable-care pathways lead not only to unequal outcomes but also to inefficiencies of resource utilization and will ultimately lead to a lack of sustainability.7

The use of evidenced-based clinical practice guidelines (CPGs) will not only boost uniformity of care but will also bring efficiency in resource utilization. Building out these changes over an entire healthcare system will multiply these effects. Learners must be taught effective use of CPGs, assimilating them into practice while adjusting for individual patient needs and faculty needs to “model” these type of treatment algorithms in order to be maximally effective educators.8

To further trainee education in this regard, expectations must be established. Although the American College of Physicians has developed a curriculum, high-value care is still not a specific training competency, and there are currently no measures for use in milestone assessments.

Teaching High-Value Care as Defined by Reimbursement
Whereas clinical outcomes and value are paramount to effective healthcare delivery, adequate reimbursement is necessary to sustain the system. However, value and reimbursement do not always correlate, especially since methods of reimbursement vary.7,9 Reimbursement itself is multifaceted and variable, based on the payer. Specific education on charges, receipts, relative value units, and price is needed if trainees are to reasonably contribute to value-based care in the context of reimbursement.10

Cost is defined as the dollar amount required for a provider to deliver a healthcare service. The charge is the amount a provider asks for a service. Reimbursement is the amount the payer, such as the insurance company, agrees to pay the provider, often based on preexisting agreements that are themselves based on diagnoses and not fee for service. Price is the amount a patient would pay directly for a service. Additionally, reimbursement can be further stratified by fees for the providers versus the hospital. In contemporary practice, although providers bill for services provided, hospital billing is based on diagnoses and is dependent on provider documentation. Therefore hospitals commonly incentivize providers to optimize clinical documentation.

Evolving educational initiatives provide education to trainees on reimbursement. The ACGME requires specific teaching on cost awareness. The NEJM Resident 360 program also offers links to high-value care resources such as the Choosing Wisely campaign. Finally, the Healthcare Bluebook has been created to list pricing for common procedures, laboratory tests, and imaging with a fair price valuation based on actual historic controls. Unfortunately, none of these resources currently provide comprehensive education.

In conclusion, affecting change in global provider mentality when it comes to value can be difficult. However, instilling high-value approaches to clinical decision-making in today’s learners not only creates a solid footing for tomorrow but also captures a group of practitioners who are the “boots on the ground” initiating many of today’s healthcare decisions. Ensuring that house staff are taught to think while keeping quality and safety in mind, practice in a uniform and efficient manner, and understand reimbursement will clearly improve the quality of healthcare delivery in the future.

References
1. National Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term Trends in Health. Washington, DC: U.S. Department of Health and Human Services; 2017.
2. Johnson PT, Alvin MD, Ziegelstein RC. Transitioning to a high value health care model: academic accountability. Acad Med. 2017 Nov 1. [Epub ahead of print].
3. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. Accessed February 26, 2018.
4. Smith CD. The rationale for high value care quality improvement. Presented at: Academic Internal Medicine Week 2017; March 19, 2017; Baltimore, MD.
5. Institute of Medicine; Committee on the Learning Health Care System in America; Smith M, et al. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013.
6. Stammen LA, Stalmeijer RE, Paternotte E, et al. Training physicians to provide high-value, cost-conscious care: a systematic review. JAMA. 2015 Dec 8;314(22):2384-2400.
7. Porter ME. What is value in healthcare? N Engl J Med. 2010 Dec 23;363(26):2477-2481.
8. Stern RJ, Parks AL. Teaching high-value care on rounds: modeling moderation. JAMA Intern Med. 2016 Feb;176(2):262-263.
9. Porter ME, Lee TH. The strategy that will fix health care. Harvard Business Rev. 2013 Oct.
10. Courtright KR, Weinberger SE, Wagner J. Meeting the milestones. Strategies for including high-value care education in pulmonary and critical care fellowship training. Ann Am Thorac Soc. 2015 Apr;12(4)574-578.