How to Control Health Care Costs: Prune Useless Tests, Speed Recovery from Surgery

Daniel Carey. Photo credit: The News and Advance.

It comes as no surprise that Virginia’s new Secretary of Health and Human Resources, Dr. Daniel Carey, supports Governor Ralph Northam’s push to expand the Medicaid entitlement. But he’s also got some ideas on how to squeeze costs out of Medicaid — and Virginia’s health care system generally.

One strategy is to decrease the use of procedures and tests that provide little value. Writes Amy Trent with the News and Advance:

He points to routine echocardiogram and routine stress testing before noncardiac surgeries as well as routine vitamin D testing, all of which can offer little value, he said. It’s more cost effective to treat most people with a vitamin D supplement rather than routinely testing vitamin D levels except in very specific circumstances, according to Carey. Physicians need to stop giving tests that are unlikely to change the care patients receive, he said.

“We need to eliminate that because it’s not cost-effective care,” Carey said.

Carey advocates implementation of the Choosing Wisely principles, launched by the American Board of Internal Medicine, which consults 100 medical specialty groups to maintain a library of overused tests and treatments.

While the state cannot mandate these measures, Carey said in a statement, “What we can do is work with the state plans, [The Department of Medical Assistance Services], and the Virginia Center for Health Innovation to not cover low-value care.”

Meanwhile, Carey wants to expand a Virginia Commonwealth University initiative that speeds recovery from surgery.

In the online publication OncLive, Dr. Traci Hedrick, co-director of the Enhanced Recovery Program at the University of Virginia Health System, writes that since her system’s implementation of enhanced recovery protocols in patients undergoing major colorectal surgery in 2013, the hospital has seen an average reduction of two days for hospital stays, an 80 percent decrease in opioid use and a 50 percent reduction in complications. In addition, “there was a $6,567 per patient reduction in total hospital costs,” Hedrick wrote.

Enhanced recovery after surgery makes sure patients are as healthy as possible prior to surgery, thereby reducing the effects of surgery on the body.

Both initiatives sound promising. The trick is implementing them in an industry notoriously resistant to change. It’s one thing to identify ways to spend health care dollars more efficiently, and it’s quite another to persuade hospitals and physicians to adopt measures which, if successful, will cut into revenues and profits.

One thing we know: Hospitals and doctors won’t implement the changes out of competitive pressure. There is no competitive pressure. Virginia health care is increasingly dominated by a handful of monopolistic health systems and giant physician practices. Moreover, there is no price transparency, so it’s not as if a hospital could gain market share by touting its lower-cost services. Virginia does have some control over the way it designs its Medicaid programs, so perhaps there is some hope in that sub-market. Otherwise, Carey will have to rely mainly on moral suasion. However, I can’t remember the last time moral suasion ever convinced anyone to act against their self interest.

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10 responses to “How to Control Health Care Costs: Prune Useless Tests, Speed Recovery from Surgery”

  1. Salary caps on admin. That doesn’t mean the billers. They are chump change. Any one who is not a HCP who earns over $100K, that’s where you start the caps. Just saw the ratio on CEO to regular pay:

  2. LarrytheG Avatar

    I would think unneeded tests and treatments could easily be handled by reimbursement caps.

    MedicAid – has lower costs per capita than private insurance and in some cases Medicare – already.

    MedicAid in Virginia is also going to a Managed Care model which means essentially that the patient has a portable medical record that goes to whatever provider is treating.

    People argue about whether that is a “risk” or not – I don’t think so – your records are already digitized and stored in databases but certainly with regard to MedicAID… it’s justified in the interests of lower costs to taxpayers… and actually in the end – people whose medical providers share the same medical history tend to have less errors and less duplication of tests and treatments.

    MedicAid is actually a good opportunity to see how costs can be reduced…

  3. Steve Haner Avatar
    Steve Haner

    When the health care professionals are talking about these issues, I tend to shut up and listen. Both of his suggestions are valid but I don’t see either moving the needle very far. When the insurance company folks and the medical administrators start talking, my skepticism rises.

    My primary doc likes to do blood tests and my cardiologist wants those lipid results, as well, so I know my way to a couple of Labcore locations. Labcore does give a list of charges for the various tests as I come in the door, but by that time of course the lab order has been placed. The delta between their official charge and their Anthem contract price is stunning, but I’ve seen the same problem everywhere and I keep coming back to that. There is an Anthem price, a Medicare price, a Medicaid price, a Tricare price – perhaps some other insurance company has its own payment schedule – its just nuts! And the person who is the most vulnerable, the one without insurance, pays the most and it becomes the basis of a bankruptcy. (Or he or she does without and suffers.)

    I have found that having an HSA and a high deductible plan does create focus on cost, since my wife and I have to spend thousands every year before real insurance kicks in. Real price transparency would help. There should always be a co-pay. But if I am asking for a referral to a specialist, I ask about quality and convenience, not cost. I will not pick my next heart surgeon on the basis of price – and I want people who become the best at what they do properly compensated.

    A couple of suggestions. Ban medical advertising, especially drug ads. Ban the practice of bribing docs and NPs and even nurses with tangible goodies passed out by the drug companies, including hard cash (my daughter the NP is always complaining about that – its rampant). Crack down on patent extensions and similar games. And the next time somebody starts a serious discussion about end-of-life issues, don’t start hollering “death panels, death panels”, because ridiculous sums are spent on hopeless cases when the family will not face reality or listen to a patient who wants to end it.

  4. LarrytheG Avatar

    I’m always struck by the facts that all other industrialized countries are all govt-run – very little “competition” and their prices are much, much lower than ours – and they all live longer…

    yet we continue on this quest that competition will lower costs …

    there’s no place on planet earth where it actually does work that way and there are plenty of potential places where it could work – about 140 developing and 3rd world countries. Even in some of these countries, it’s the govt that provides basic clinics and the like while those with wealth “shop around” (I guess).

    And I’m with Steve on selecting Doctors but the thing is when you go into a hospital for a major procedure – you might think there is one guy but there are usual several.. and you don’t have a clue who they are or whether they meet your wants for “quality” and “price”.

    And for the record – my own Primary Care doc does NOT know who my cardiologists is – even though he does send copies of his medical records on me – to her. It goes into my paper folder to never be seen again – and I KNOW THIS .. because the last time in she referred me to an entirely different Cardiologist!

    When the Primary Care and specialists do not share electronic records – but instead paper.. this is what happens.

    1. Steve Haner Avatar
      Steve Haner

      You’re right, in this cloud-based society, that’s pretty sad, and it should be easy to fix. Amazon, Google and Facebook probably know plenty about you – and will sell it for a price.

  5. “Physicians need to stop giving tests that are unlikely to change the care patients receive, he said.”

    Well, Jim, you threw that out there and nobody has commented on it so far except to suggest reimbursement caps: i.e., more regulation (a reimbursement cap) to fight the distortion of the marketplace caused by regulation, i.e., medicare reimbursement standards, which reward undue testing unnecessarily.

    Let’s go back and look at the root cause of this: the undue testing. Why?

    It seems to me, the reasons doctors test too much are: (1) it buys time and provides more information for busy G.P.s, the front line diagnosticians; (2) its cost is reimbursed without much question; (3) it helps dispose of the questions of skeptical patients even if the G.P. already knew the answers; (4) there is NO (as in NONE, ZERO, NADA) incentive under current reimbursement arrangements to get the diagnosis to the patient quickly and at lowest cost — the only reason to hurry is to keep the patient happy, and many patients don’t have a clue when to complain or the leverage to do so.

    I’m for fixing Medicare (on which many other medical mechanisms are based implicitly if not explicitly) to provide more emphasis on quality of outcome, not merely to provide fixed reimbursements for approved procedures. If the Republicans (or any politicians for that matter) want to make a difference in the total cost of health care without abandoning universal coverage, it’s the reimbursement mechanisms that MUST be tackled. We’ve spent all this time arguing over payment mechanisms and insurance; the real tough nut to crack is “quality of care.”

    1. Steve Haner Avatar
      Steve Haner

      Sometimes the tests are ordered just as CYA in this litigious age…

  6. LarrytheG Avatar

    in every other industrialized country – the “tough nut” of “quality of care” has apparently already been cracked as this country is dead last in life expectancy compared to those countries.

    And it’s not because, across the board, we are last. In places like Fairfax, the life expectancy rivals the best countries in the world but in other places in our country – life expectancy rivals 3rd world countries.

    So… it’s NOT like we do not have mechanisms for “better outcomes” in this country; we clearly do and those longer life expectancies in places like Fairfax – clearly demonstrate that fact even though they have the same doctors and same insurance and same level of “transparency” as the other places that don’t.

    To put this a different way – if Fairfax can rival other countries in life expectancy then why can’t the rest of the country also?

    not a trick question… there’s an obvious answer..

  7. Steve Haner Avatar
    Steve Haner

    Unfortunately health care is like education – we expect it to be “provided” without taking any personal responsibility or providing any personal effort. Hell, I can’t be the problem myself!! Smoking, bad diet resulting in obesity and diabetes, lack of exercise, drug use – spend some time in the waiting rooms and its pretty darn obvious what drives health outcomes in general. If indeed there are differences by region, take a look at those factors and see if they might play a role (certainly access to care does too). When I went under the knife part of my problem was a hereditary defect but the double bypass was entirely the fault of the cheeseburgers and middle age spread. I might be living still with the bum valve but for that 20 years of stupidity (now corrected).

  8. CleanAir&Water Avatar

    Medicine has gone corporate and needs a whole lot more change than advocated here. As someone who keeps running aground of medicine because of missed diagnoses etc, and now a hip replacement operation gone bad … I have been following Functional Medicine since the early 90’s. Their prime raison detra is not treating symptoms but finding and treating causes. They cure type2 diabetes for instance! The ability to do so has been around for 15 years but ….

    Now Functional Medicine practitioners are trying to be much more visable and venturing into insurance. Here is a webinar FYI

    The DR who I have been following, Mark Hyman, is now at the Cleveland Clinic where he is ‘spreading the word’.

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