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High Value Care at UCSF: Striving to provide the best care at lower costs. Christopher Moriates, MD Division of Hospital Medicine GME Grand Rounds, UCSF February 18, 2013. Financial Disclosures. Within the last 12 months, I have received:

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high value care at ucsf striving to provide the best care at lower costs

High Value Care at UCSF: Striving to provide the best care at lower costs

Christopher Moriates, MD

Division of Hospital Medicine

GME Grand Rounds, UCSF

February 18, 2013

financial disclosures
Financial Disclosures
  • Within the last 12 months, I have received:
    • A grant from the ABIM Foundation for a project exploring cost-related curricula in medical education
as an intern i rotated through the emergency department
As an intern, I rotated through the Emergency Department…

"To improve emergency room throughput we've replaced the front door with a CT scanner."

Cartoon from ACP Internist Weekly Caption Contest 7/3/2012. Caption by Brett Montgomery, MD, from Richmond, Va

how much does this cost
How much does this cost?

Illustration by Peter Arkle

Bloomberg.com 7/11/11

cost of headache evaluation
Cost of Headache evaluation
  • CT Head
    • Minimum : $750 - (Altus, OK)
    • Average : $1,150  
    • Maximum: $4,200 - (Ketchikan, AK)
    • UCSF: $1,800 - 2,475
    • SFGH: $1,800

SOURCE: Newchoicehealth.com (accessed 12/29/11)

cost of headache evaluation1
Cost of Headache evaluation
  • MRI Brain
    • Minimum: $1,650 - (Andrews, TX)
    • Average : $2,550  
    • Maximum : $7,300 - (Ketchikan, AK)
    • UCSF: $3,600 - 6,600
    • SFGH: $3,000 - 6,000

SOURCE: Newchoicehealth.com (accessed 12/29/11)

why show you the costs
Why show you the costs?
  • It is part of physician’s professional responsibility to use healthcare resources judiciously
  • Physicians need to be trained about healthcare costs
  • Astounding amount of healthcare waste and “unnecessary testing”
  • It is important to the patient in front of us
today s agenda
Today’s Agenda
  • Motivations for considering Healthcare Costs
  • How are we teaching residents?
    • The UCSF Cost Awareness curriculum
  • How do you operationalize these ideals?
    • Highlight Three High-Value Care Projects
  • How is UCSF addressing this campus-wide?
    • The Center for Healthcare Value
  • Conclusions
it is about the patient in front of us side effects may include financial ruin
It Is About The Patient In Front of Us!Side-Effects May Include: Financial Ruin

HimmelsteinDU, Warren E, Thorne D, Woolhandler S. MarketWatch: Illness And Injury As Contributors To Bankruptcy. Health Affairs, no.W5(63), 2005.

Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009;122(8):741–6.

Medical bills are the leading cause for personal bankruptcy in the United States

Middle-aged, college-educated, homeowners

>75% were insured!

an uninsured patient s perspective
An Uninsured Patient’s Perspective

Clip courtesy of This American Life from WBEZ Chicago

it is about the patient in front of us putting off care because of cost
It is About the Patient In Front of Us:Putting Off Care Because of Cost

Percent who say they or another family member living in their household have done each of the following because of the cost:

Relied on home remedies or over-the-counter drugs instead of going to see a doctor

Skipped dental care or checkups

Put off or postponed getting health care needed

Not filled a prescription for a medicine

Skipped a recommended medical test or treatment

Cut pills in half or skipped doses of medicine

Had problems getting mental health care

‘Yes’ to any of the above

Source: Kaiser Family Foundation Health Tracking Poll (conducted May 8-14, 2012).


Exploding Health Care Costs

Since 1987, US health care spending per capita has more than doubled, and the cost borne by patients continues to rise.

Chart design: Luke Shuman
Sources: Archives of Internal Medicine, US Centers for Disease Control and Prevention

Andy Grove, Wired, 2012

two separate motivations to consider costs
Two separate motivations to consider costs:

1. Macroeconomic resource stewardship

2. Financial safety of the patient in front of us

the sweet spot where these two motivations align
The Sweet Spot: Where these two motivations align

Good for Society


for Individuals

For example: Generic Drugs

ucsf also has an additional motivation
UCSF also has an additional motivation…

Next Up: “The scariest slide (UCSF) will see all year”

– Dr. Mark Smith

The Narrow Network Threat: Consumers want low premiumsand are willing to trade off narrow networks to get them

Relative Preference of Benefit

Respondents were given a maximum difference trade off exercise in which they were forced to choose the most preferred and least preferred plan feature.

Base: All US Adults Less than 65

SOURCE: Strategic Health Perspectives 2012 Consumer Survey

Slide from Mark Smith, MD – California HealthCare Foundation

it s about the patient in front of us
It’s About the Patient In Front of Us:

If we don’t figure out at UCSF how to provide our patients and their insurers with higher value care:


previously widely ignored in medical training
Previously widely ignored in medical training:

“The reasons for this silence are historical, philosophical, structural, and cultural. ...Combating such forces is a tall order, but I believe that medical educators have an obligation to address cost.”

- Dr Molly Cooke (2010)

Reference: Cooke M. Cost consciousness in patient care--what is medical education's responsibility? N Engl J Med 2010;362:1253-5 :

the acgme also says so
The ACGME also says so…

“Residents are expected to… incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.” - ACGME

Under the Systems-Based Practice core competency requirement:

The Milestones Project will present many Cost-Related Milestones

Reference: ACGME: Common Program Requirements. 2007. (Accessed 10/25/2010)

global objectives
Global Objectives

Increase Awareness

  • To increase medicine residents’ awareness of value, quality, and cost in medicine

Improve Attitudes

  • To improve physician attitudes regarding sustainable spending

Change Behavior

  • Cultivate more cost-effective physician ordering behaviors


How the curriculum is delivered


“Core” topic and case assigned

Interns divide into two groups

Guideline Review

Case Analysis

  • Review literature
  • Find evidence based best-practice guidelines
  • Suggest cost effective workups
  • Review recent case from our institution
  • Analyze hospital bill, and clinical chart to evaluate care provided
  • Reflect on our own clinical behaviors

Case review debrief

Case based noon conference for ALL residents


Case-Based Noon conference shared with students, residents, and attendings.

Includes concrete “Action Items”:

2 things to “Start” and 2 things to “Stop” doing based on the conference

health care system
Health Care System

IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press.


UCSFCost Awareness Curriculum:


  • Pilot: 176 evaluations from 10 conferences
  • Highly relevant to their clinical practices
  • (mean, 4.6 +/- 0.6 on a 5-point Likert scale; median, 5)
  • Likely to change their ordering behaviors
  • (mean, 4.3 +/- 0.7; median, 4)

Moriates, et al. JAMA Int Med, 2013


Through modules detailing common admission diagnoses, he emphasizes the principles of evidence-based medicine and provides information about associated costs…



…the purpose of this curriculum is not to teach rationing health care; it’s to teach rational health care. By learning the fundamentals of evidence-based medicine, but keeping the best interests of the patient in mind, we’ve learned how to use the most current guidelines to provide

individualized yet cost-effective care.

Two residents’ experience with the curriculum:


let me tell you about my ucsf patient
Let me tell you about my UCSF Patient…

65 year-old woman with a recent diagnosis of COPD

Started on albuterol inhaler 1 month ago by primary doctor

She has “attempted to use the inhaler” but has noted increased wheezing and productive cough

In the Emergency Department: Started on continuous nebulized bronchodilator therapy, given Solumedrol 125mg, doxycycline, Chest X-ray and CT Chest

so what happened to our patient
So, what happened to our patient?

Around-the-clock nebulized bronchodilator therapy (“Nebs”) every 4 hours x 3 days

Transitioned to Metered-Dose Inhalers (MDIs) prior to discharge on her last hospital day - Never received dedicated inpatient MDI teaching!

ms j total estimated hospital bill
Ms J. - Total estimated hospital bill

Summary of current charges

Room at $7,277 x4 days $29,108

Pharmacy $3,969

Lab $4,394Supply/Devices $2,272

Radiology $250

CT Scan $2,755

Respiratory Services $4,605

Emergency Room $2,277

EKG $380

Total of Current Charge



Physician fees billed separately

ms j respiratory care charges
Ms J – Respiratory Care Charges

Continuous Nebs per hour = $104

Small Volume Nebs Treatment = $258 each

the cost
The Cost

During Fiscal Year 2012, the medicine servicealone spent more than $1MILLION on 25,114 nebulizer treatments for 1200 NON-ICU patients

UCSF Spent >$3.5MILLION hospital-wide

the evidence nebs vs mdis
The Evidence: Nebs vs MDIs

Mandelberg A, Chen E, Noviski N, Priel IE. Chest. Dec 1997;112(6):1501-1505.

Dolovich MB, Ahrens RC, Hess DR, et al Chest. Jan 2005;127(1):335-371.

Turner MO, Patel A, Ginsburg S, FitzGerald JM. Archives of internal medicine. Aug 11-25 1997;157(15):1736-1744

Systematic reviews: No significant difference between devices in any efficacy outcome in any patient group

Studies: Bronchodilator delivery by an MDI is equivalentin acute treatment of adults with airflow obstruction.

patients misuse their inhalers
Patients Misuse Their Inhalers!

Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. Journal of general internal medicine. Jun 2011;26(6):635-642.

Recent study:

86% of patients misused their


(some did not even take the cap off!)

All of them (100%) were able to achieve mastery after training!

current philosophy
Current Philosophy
  • Focus now on the “low-hanging fruit”: interventions with low or no benefit
  • Goal: Reduce inappropriate care that does not help (or even harms) patients
  • Ultimate outcomes: better patient care, reduced cost
the case of ionized calcium ical
The Case of Ionized Calcium (iCal)
  • Direct Variable Cost at UCSF:
    • iCal: $20.20
    • Serum Ca: $0.49
  • In FY2012 the Medicine Service:
    • 7400 iCal labs
    • Direct Cost: $149,472
    • 40% of all ca+2 labs drawn were iCal
    • 42% of all iCal labs were drawn on NON-ICU patients
clinical significance of low ical
Clinical significance of Low iCal?
  • Studies suggest: abnormal iCal is likely a marker of illness severity rather than an independent contributor to mortality
  • Cochrane Review: “There is no clear evidence that IV ca+2 supplementation impacts the outcome of critically ill patients.”
      • Study involving >58k iCal tests: 75% reduction in iCal lab draws showed no effect on mortality, cardiac arrests, or seizure activity
  • Egi, M; Kim, I; Nichol, A; et al. Ionized calcium concentration and outcome in critical illness. Critical Care Medicine 2011 vol 39, No. 2
  • Forsythe, RM, Wessel CB, Billiar TR, Angus, DC, Rosengart, MR. Parenteral calcium for intensive care unit patients. Cochrane database of systematic reviews (2008)  issue: 4
  • Baird, GS, Rainey, PM, Wener, M, Chandler W. Reducing Routine Ionized Calcium Measurement. Clin Chem. 2009 Mar; 55(3): 533-40.
why do we do this
Why Do We Do This?

Are We Treating The Patient In Front of Us?

Are We Connecting the Evidence to the Care We Provide?

Cartoon by T. McCracken


high value care committee
High Value Care Committee

iReduce iCal:

Draw Ionized Calcium Only When Needed


stress ulcer prophylaxis project

Stress Ulcer Prophylaxis Project

An Initiative of UCSF Medical Center and the Medication Outcomes Center

Stress Ulcer Prophylaxis Project


  • Widespread use of stress ulcer prophylaxis (SUP) in the ICU
  • At UCSF the majority of ICU patients (over 80%) are on SUP and 19% do NOT meet indications for this
  • Risks associated with therapies include pneumonia and Clostridium difficilecolitis
stress ulcer prophylaxis project1

Stress Ulcer Prophylaxis Project

An Initiative of UCSF Medical Center and the Medication Outcomes Center

Stress Ulcer Prophylaxis Project


  • Decrease use of inappropriate acid suppressive therapy in the ICU by 25%

QI bundled Intervention:

1) Evidence-based guidelines

2) Pharmacist-led intervention

3) Education/Awareness Campaign

high value care projects lessons learned
High-Value Care Projects: Lessons Learned
  • Strategy:
    • Stakeholder Recruitment and Buy-In
    • Education
    • Promotional “campaigns”
    • Audits and Feedback
    • Systems changes / Forcing Functions
  • Like previous QI work, these projects require an “all-of-the-above” approach
  • But, need even more emphasis on education, convincing stakeholders, and careful messaging!
  • Instead of asking providers to:
    • Start doing more of something you already know you should be doing (DVT prophylaxis, Hand Hygiene, Checklists)
    • Stop doing something that you already do!

The Center will bring UCSF to the forefront in addressing the unsustainable costs of healthcare. 

training initiative
Training Initiative

First result:

  • List of competencies supporting cost-consciousness for multiple levels of trainees developed

Next step:

  • Implementation plan for competencies
med center initiative
Med Center Initiative

First Results:

  • Switching IV to PO early in hospital stay
  • Ideas Contest – More than 140 Ideas from UCSF Community
  • Project Funding – Open Proposals
media culture change
Media/Culture Change

Goal: to develop a strategy to reduce cultural barriers to long-term change in practice, building upon existing regional and national practice and educational campaigns.

additional initiatives
Additional Initiatives
  • Price Transparency Initiative
  • Systematic Reviews Initiative
  • Translational

Research Initiative

  • Payer Initiative
choosing wisely at ucsf poised to be national leaders in healthcare value
“Choosing Wisely” at UCSF: Poised to be National Leaders in Healthcare Value
  • “Choosing Wisely” = DOM priority
  • Cost Awareness Resident Curriculum
  • High-Value Care Committee
  • Center for Healthcare Value
what you can do about it choosing wisely at ucsf
What YOU Can Do About It:“Choosing Wisely” at UCSF

Help the patients in front of you:

“Nebs No More After 24!”

“iReduce iCal”

“De-STRESS Your Patients”

IV-to-PO medication initiative

  • Future Projects:
    • Clinically-indicated

PIV replacements

    • Antibiotic stewardship
our future together
Our Future Together
  • THE BEST CARE AT THE LOWEST COSTS for our patients
  • Help disseminate education


  • Contribute to the national

movement for better healthcare value

  • Popularize stories about the harms of overtreatment and

healthcare costs

less is more trainee perspectives accepting articles now
“Less Is More” Trainee Perspectives - (Accepting articles now!)

Brief articles that present patients' and physicians' perspectives on their health care experiences, with special emphasis on examples when more care is not always better, even to the point where it is perceived as harmful.

Maximum specifications: 300 to 500 words, 2 authors.


Questions / Comments



Dr. Michelle Mourad

Drs. Neel Shah and VineetArora

Dr. Bob Wachter

Drs. Andy Lai, KrishanSoni and SumantRanji

The High-Value Care Committee

Dr. Steve Ludwin

Dr. Stephanie Rennke

Dr. Ted Omachi

Maria Novelero

Katie Quinn

UCSF Internal Medicine Residency Program

Drs. Harry Hollander and Brad Sharpe

Drs. Kara Bischoff and Seth Cohen

UCSF Center for Healthcare Value

Lisa Schoonerman

Drs. Clay Johnston and Deb Grady

Dr. Rita Redberg

American College of Physicians

Dr. Molly Cooke

Dr. Daisy Smith

Health Professional Education Pathway

ABIM Foundation

Dr. TalmadgeKing

Our Patients