Cost Consciousness in Health Care: Value Value

This from the New England Journal of Medicine in an article by Molly Cooke:

It is old news that the cost of medical care in the United States is unsupportable, yet we seem unable to grapple with the issue effectively. As current ideas for health care reform have percolated through Congress, cost-control mechanisms have generally been recognized as the weak component. Our country is remarkably generative in the development of new diagnostic tests, drugs, and procedures — and remarkably undisciplined in their deployment. New diagnostic and therapeutic procedures and the broadened application of established ones account for two thirds of the growth in health care expenditures.

Cooke believes medical schools and teaching institutions have a responsibility to teach cost consciousness in health care. Such a responsibility would seem natural given that health care is the largest expense of many people’s lifetime.


Philosophically, we physicians have conceived of ourselves as, and taught students that we are, advocates for each patient, obligated to eschew all considerations other than benefit to that patient and his or her preferences.


A predominant driver of the cost of hospital care is the length of stay, so a high priority is readying patients for discharge — which serves as a rationale for preemptively ordering any test and consultation that might be called for, to avoid delaying discharge. Consequently, students and residents have scarce opportunity to practice devising cost-effective diagnostic strategies and explaining their rationale to patients and families.


Finally, cultural values powerfully influence the selection of teaching topics. Academia celebrates the “high knowledge” of medicine: pathophysiology, molecular biology, genomics. Even evidence-based medicine, although it deemphasizes fundamental mechanisms, is regarded as acceptably intellectual in comparison with “low,” real-world concerns such as cost.

Medicynical Note: Teaching cost consciousness would apprear to be a no brainer given the near 17% of GDP spent on health care, the excessive costs of health care in the U.S. compared with elsewhere, the high medical related bankrupcy rate in our country, and our yearly excessive increase in health care costs. The article goes on to point out the urgent need to change and to value value!

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