Impatient | Helping make the health care system work for you

Showing doctors the way to lower cost, improved care

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As regular readers of Impatient know, I've been on a mission recently to encourage consumers to talk with their doctors about health care costs.

Everyone I've spoken with for this series - patients on high-deductible health plans, patient advocates and a few doctors - agrees that through these conversations, patients and doctors can work together to potentially lower people's out-of-pocket costs.

But as Duke University professor Peter Ubel points out, patients can only have so much influence over their doctors' recommendations.

"One of the biggest limits to the power of health care consumerism - of patients to discipline the health care marketplace - is the fact that doctors make most of the medical decisions," Ubel tells me.

He offers this example:  If a patient goes to see a doctor for back pain, and the doctor recommends an MRI, the patient can shop around for the most affordable MRI. But, he says, "I, as a patient, might not know that I didn't need any MRI."

Convincing doctors to avoid ordering unnecessary tests, or avoid prescribing expensive brand name drugs when generic versions are available, requires a larger, cultural shift in health care. One health system in Northern California has developed a way to concretely change physicians' behavior.

Could this be a model for a cultural shift toward more cost-conscious, high-quality care?

'They want to do the right thing'

Groups of doctors at Sutter Health, a non-profit health system based in Sacramento, gather two or three times a week to examine how their practice patterns differ from those of their peers. It's an opportunity to see which doctors are providing high-quality, affordable care, and then learn from each other, says Michael Van Duren, who, as vice president of variation reduction at Sutter Health, oversees this initiative.

"If people are doing things really differently, and they both get the same outcomes, then maybe it points to an opportunity where we don’t need to be doing so much testing or imaging," Van Duren says.

The meetings work something like this: Van Duren will choose a common recommendation, such as prescribing anti-ulcer medications. Then, using data from electronic medical records, he'll project doctors' prescribing patterns on to a wall. The information is personalized, so they can see how they compare with their peers.

In the case of the anti-ulcer medications, some doctors were prescribing brand name drugs, which cost about $200 for a monthly supply, while others were recommending the generic version, for $4 a month.

Once the doctors heard from their peers that the generic drug worked as well as the more expensive ones  and was much easier on patients' wallets, they changed their prescribing habits, Van Duren says.

"We discovered that they're actually scientists at heart, and they're very curious, and they want to do the right thing," he says. "When they're exposed to how different they are, and they hear their colleagues saying, 'this more affordable way works just as well,' we were shocked and surprised to see that they changed the next day.'"

Van Duren says the initiative started five years ago, and has grown steadily ever since. He is now tracking about 450 different procedures, tests and prescriptions, and says the effort has resulted in $30 million in savings in the last two years. "It's for society, or I say, 'it's for your grandchildren,'" Van Duren says, noting that depending on the project, the savings could benefit a health plan, the hospital or a patient with a high deductible.

Motivated by patients

When he first introduced this initiative, Van Duren says he faced resistance from doctors. To them, the effort to identify the most cost-efficient best practices sounded like a mandate from an insurance company, or a hospital CEO who doesn’t understand medicine.

But there are several reasons it's been effective, he says.

For one: As I've reported, more people are on high-deductible health plans, and are responsible for a large chunk of their medical bills. So more people are asking doctors why they ordered an expensive test or prescribed a costly medication when there were cheaper options.

He explains that the conversations I've been encouraging y'all to have are spurring doctors to be more cost-conscious, and more open to these projects.

"The patient impact is actually what motivates this," he says.

Another reason: When it comes to what particular tests, procedures or medications cost on particular health insurance plans, "doctors are operating in the blind," Van Duren says. These sessions, he says, provide doctors with information to which they’ve never had access.

Van Duren cited another project he led: He examined how dermatologists prescribe an ointment to treat dermatitis. A cream can be $19, but it turns out that the same formula in spray form can be $387, he says.

"These doctors have no idea what these things cost," he says.  When they find out they could've recommended a far more affordable option to their patients, they feel terrible - they don't want to be doing that."

Peter Ubel offers another reason that this effort works: "Very few human beings on the planet are more competitive than physicians," he says with a chuckle. "You start showing them how they're doing compared to someone else, and they want to be at the top. It's brilliant."

Of course, the savings generated from these projects would be worthless, if they weren't maintaining or improving the quality of care. "Almost always," Van Duren says, "when we approach an affordability problem, we'll ask, 'how would we measure the quality outcome along with this?'"

An example: Van Duren says doctors often order CT scans for people who arrive in urgent care with bellyaches, to rule out the likelihood of appendicitis. So if physicians try to reduce the number of CT scans they order in urgent care, Van Duren says he'll make sure they're not missing preventable problems, by tracking how many of these patients later end up in the emergency room with ruptured appendices.

Share your experience

Of course, this is just one health system’s effort to achieve cost-conscious, high-quality care. As I learn about more, I'll share them with you. And if you know of any efforts like this, please pass them my way!

In the meantime: Has anyone had any success - or challenges - talking to their doctors about their health care costs? Share them in the comments section below, or e-mail me at