 So, it's my pleasure in Mark's place today to welcome our speaker on behalf of the McLean Center, the Center for Health and the Social Sciences and the Bucks Baum Institute for Clinical Excellence. Our speaker in today's instance of our lecture series on the present and future of the doctor-patient relationship is Dr. Andrea Leep. She is an Assistant Professor of Neurology at the Mayo-Alex School of Medicine located in Rochester, Minnesota. She's a consultant there in the Education Division of the Department of Neurology, and in addition to her consulting, she's Director of the Learning Environment and Education Culture for the Mayo Clinic School of Medicine, also the Co-Director of the Karen National Network for Caring and Character in Medicine and Associate Director of the Mayo Clinic in Professionalism and Value, and the Quality Chair for the Department of Neurology at Mayo. Dr. Leep received her medical degree at Mayo Clinic and then stayed there completing her residency in Neurology and a fellowship in Clinical Neurophysiology before joining the faculty there. Somewhere along the way, she also obtained a Master's in Health Professions Education from the University of Illinois in Chicago, and we have some of our faculty who have also done that, and we really love that program. Dr. Leep's mission is to support healthcare faculty, staff, students, and leaders in co-creating environments that reflect shared professional values to promote learning and to serve patients. Her professional interests include professional identity formation and professionalism, character formation and expression, as well as performance assessment and performance enhancement. She also strives to teach her trainees about the cost-effectiveness of care, and her talk today is entitled, High Value Care, Counting the Cost. Please join me in welcoming Dr. Leep. Thank you all for having me here today. I want to start out by inviting you all to reflect, to think back to the last time that you had an encounter with a physician or some sort of healthcare clinic. Why were you there? How did you feel? That situation in your mind. And then think, did you notice anything about cost-conscious care and that in account? Did you notice anything? If you did, do you think it promoted your relationship with that individual or maybe you didn't notice it at all and wished you had, or noticed it and wished you hadn't? Did you even think you had a relationship with a person you saw? Those are some of the questions I'm hoping we'll be able to unpack together. But before we dive into the details, let's step back a little bit and ask ourselves why we're talking about cost-conscious care and the physician-patient or patient relationship in the first place. How many of you have seen a graph that looks something like this? Yeah, most of us have, right? Healthcare spending is, you know, relentlessly increasing over time. One out of five dollars in our economy spent on healthcare, totaling 8.2 trillion dollars in 2019. This is twice what's spent on healthcare in other developed countries. Without a commensurate return on that investment in terms of health outcomes. At least that's what many argue, showing charts like this, where life expectancy is plotted against per capita spending. And you can see that the U.S. is a clear outlier here, spending more than anyone else without a life expectancy gain to show for it. More sobering are estimates that the order of the spending is wasted on inefficient, ineffective, unnecessary, overpriced, or fraudulent services. Now as a physician, this is startling to me. If I didn't go to medical school to treat the GDP, right? And we've heard people say that. We're here to think about the physician-commissioned patient relationship. So what do these individuals think about this, what's been called crisis of health care costs? The surveys of physicians show that the majority agree they should be solely devoted to individual patients' best interests, even if that's expensive. The Mayo Clinic would say the needs of the patients are first. And the vast majority disagree with what could be described as rationing, denying beneficial but costly services to certain patients because they should go to other patients who need them the most. But at the same time, 85% of physicians think they have a responsibility to try to contain costs and think physicians should take a more prominent role in limiting the use of unnecessary tests. These survey responses seem potentially conflicting and likely reflect the tensions that we in health care face between meeting the needs of the patients in front of us and stewarding societal resources on behalf of all patients. Folks have asked them what they think too and the vast majority agree health care costs are a major problem in the United States. But when you bring it down to that clinician-patient relationship you want to see that conversation happening there. How do I feel it costs the society a part of the conversation? Physicians supposed to be my advocates. Cost of my insurance company? Let's debate that in the halls of Congress. I don't want to have this debate in my physician's office to my health and that statement. Let my doctor be my doctor. Let's keep the two separate. And I think this one sums up how many feel. How can you put a price on my wife? Some tests are only going to save a few lives. But what if one of those lies is true? And it's understandable when you're in a situation where your health is at risk, the health of someone you care about is threatened, that that's going to be the most salient thing in your mind. Not the more infangible idea of societal resources. So different strategies have been devised to help clinicians engage patients in cost-conscious conversations to help them weigh that cost to society when making decisions. I'm going to share five of them and I want you to listen and think. Because at the end I'm going to ask people to raise their hand and both for which of the five they think patients like the best. So here's number one, fairness. Everyone's interested in keeping health care costs down and we're trying to do it in a fair way. In this situation, I would recommend a CT scan to all of my patients instead of an MRI. Okay, strategy one, fairness. Strategy two, shared sacrifice. It's good for us to share responsibility for keeping costs down. At the end of the day, we all pick up at the tab and we pursue an expensive fare because premiums rise. So keeping costs down is good for you and your wallet. Number three, good enough. I really think a CT scan is a reasonable option. You might not find quite as many things as an MRI but I believe it will find the important things and it's certainly good enough for what we're trying to do. Four, shared decision-making. What are your thoughts about going with a CT scan? Let's talk whether the MRI's worth that extra $500 that your insurance or Medicare Medicaid are going to do. Or maybe five, all should miss the appeals. Not taking antibiotics for your sinus symptoms now will help prevent antibiotic resistance. And that means when someone else needs antibiotics for a serious infection, they'll be more likely to help. So what do you think? Who thinks number one, fairness, which one do you like the best? Any votes for number one? Okay, I have a couple votes for number one. It's fair, treating all the patients the same way. How about number two, shared sacrifice. People don't like that one as much, right? Sacrifice means having unpleasant. How about good enough? Never argue better, but a CT's good enough for what our purposes. So we have at least a vote for good enough. Two, three, yeah, four. How about shared decision-making? All right, you want to be able to like weigh the societal cost across your insurance company and let them decide. How about altruistic appeals? I kind of like this one. You know I'm making a decision that's pretty good with everybody. But people have studied these approaches with patients and have been react to different types of strategies. And guess what? They didn't like any of them. Basically, the quads for these qualitative focus groups are something like this. The doctor's going to tell me to recommend a CT scan basically because it's cheaper. There's nothing he can say to make that sound right. Or this one I got a kick out of. It's totally funny because I agree with that thing about keeping costs down and helping me in the long run. But I don't want my doctor to say that to me. I might say it to him, but I don't know how he can say it to me. So none of these strategies really seem to resonate with most patients. Learning about what conditions and what patients think about this idea of societal costs and considering those costs of the physician-patient relationship. But what did it actually do in practice? And this is the work of the Dartmouth Atlas Group who's been creating maps like this for quite a long time when they look at regional variations in healthcare spending. And you can see this one's from some years ago now. But I grew up in Earl, Montana. And it's usually the pale end, right? It's not a lot of the capital spending relative to other places in the country where there's much, much more. And you think this difference in spending might be related to better outcomes. More bang for your buck. Well, there's more services. In higher spending areas, there's more beds. There's more physicians. There's more specialists. But you can see on this slide there's not a little convincing case to be made that outcomes are better for all that extra expense. Higher mortality, worse care coordination. And even if patients aren't that much happier, well, sometimes they are less happy with their care. So this mismatch also, it provided another way of highlighting the fact that there's waste in the system and that some of the spending must be unnecessary. And how like spending more leads to worse outcomes? That's sort of counterintuitive. But you can see that the more care there's more diagnosis, more treatment, more review, and more potential for all sorts of harms. It's also interested in my role of learning environment of how these regional variations impact our future physician workforce, our learners. And studies of residents have shown that the intensity of care in the region where they live through the residency training predicts their future knowledge, their future attitudes, and their future behaviors with respect to cost-conscious care. These associations have led folks who have hypothesized that there may be this imprinting process whereby residents start to develop practice patterns that resemble those they see in their learning environment. But what about medical students? So we did some surveys of medical students across the country at 9 or 10 different schools, geographically dispersed. We first looked at their attitudes for cost-conscious care and they differ significantly from physicians, even those that were youngest and most proximate to them in age. And overall, we're more favorable toward cost-conscious care. We can talk about why that may be. And they report engaging in cost-conscious, high-value behaviors themselves. So they'll ask questions about the cost of care or try to figure out how much something costs. But they also report engaging in behaviors that are not very cost-conscious and are low-value, such as ordering a test just to show off their ability to generate a wide differential diagnosis. I remember wanting to do that at medius-wipples disease, you know, something along the lines. Or satisfy curiosity or build clinical experience when you're ordering an ABG because you're trying to learn how to draw blood gaps. Right? Some of these examples are widely lit for medical students of things not to do. And we looked at whether these self-recorded behaviors related to care intensity in the region of their medical school. And indeed, the students who were in more intense utilization regions recorded more low-value behaviors. So this imprinting process may start even earlier than residency for affecting our medical students in their very beginning work shifts. What is it in the learning environment? And we hypothesized that role modeling may have a particularly influential role. So we then did surveys to look at what role modeling behaviors our students were recording seeing in a clinical learning environment. And they see cost-conscious behaviors. They see physicians discussing costs of care or explaining why a test is unnecessary and would generate an unnecessary cost. But they also see potentially wasteful behaviors. Unnecessary referrals ordering more expensive things because that's what a patient asked for. Or criticizing a training for failing to order something on a stable routine labs on a stable patient. And when we combined these into cost-conscious and potentially wasteful role modeling scales we saw that students in regions with more intense use of resources higher spending saw fewer cost-conscious role modeling behaviors or reported seeing fewer such behaviors. So it's clear, I think, that our learning environment the culture of the practice of medicine is not only an issue for clinicians and patients now, but it's something we need to think about for the future physicians that we're training up to engage in those relationships down the road. This is my first place-holder slide to pause and see if you have any questions. I think we can make time for a couple questions now and we'll have a couple more opportunities a lot more later. I have a question. Yeah. So how much do you think somebody like me and Dr. McGregor really affects how the really good student has to do in the future? So- How much can we learn and how much can- I mean, how much of what we do here is teaching What do you- That's a great- It's a great question. So people have asked the students that question. There's an interest in measuring the learning environment as part of the accreditation expectations of medical schools. So people have measured all sorts of different dimensions of the learning environment and asked students to write the things that are the most influential and role-modeling consistent in relationships with faculty consistently comes out on top. So the students say it makes a difference. Now, how durable is that difference? Well, those studies- Now, these are of residence, but where they train predicts their practice patterns by 10, 15 years down the road. So that suggests it has a pretty durable response, at least in residence. Now, whether that- What happens during medical school may be trumped by what happens in medical studies. Yeah. I don't know if anyone has looked into that, but it's an interesting and important question. Yeah. How do you expect attending presidents to teach and educate patients and students and people lower their guard about cost-conscious care when they don't even know how much of something costs themselves? Right. So lab of cost transparency is a big barrier for every stakeholder, right? It's a barrier for the clinicians, for the patients, for the workers. So- And we'll touch on this later about what people have advocated Dr. Aurora and others for this idea of having universal precautions. We don't know how much the test is going to cost for this patient right here with their insurance in this hospital at this time and place in the world, but let's treat as if it could be a burdensome expense to them and the rest of the society and what can't you do to be mindful of that? I think also just being explicit because sometimes this reasoning is happening inside our heads, but it's not coming out of our mouths in a way that's explicit to learners. So one of the theories I have if we go back around why aren't regional practice patterns associated with more potentially wasteful behaviors? And it could be that a student's not in a position to recognize how much something costs or whether it was necessary or unnecessary or if the attendee ordered the test just to protect against malpractice or for some other reason. So those influences in the environment might be less visible to students and it's under reform. We want to be there. Yeah? I imagine it's hard to change the culture in medical school and instead of trying to do that I wonder about just rating medical schools on cost consciousness and that way applicants can direct themselves according to their career. That's an important thing to them in their career. So the Dartmouth Atlas has done just that as they used to have a website that was targeting the students and shared this type of data with them you might want to think about where you go to train and make a choice deliberately that's going to inculcate you with this high value lens. There's also some of the more provocative conclusions from those studies and residents where should the U.S. government allocate the money to GME education according to regional healthcare intensity you're spending and try to shift it in that fashion. So those are some of the conversations that have definitely happened as a result of this one. Yeah, one more question. I would like to look at this and looking at trends and training evaluations and cost consciousness. Yeah, I think that's something we've thought long about at Mayo Clinic because I know that I was a student I think if I had said, are you sure that might not I don't think the results are going to change management or I didn't order a lot of things I would be worried that I might get a worse evaluation. So how could we put these items at a more granular level on the students of faculty evaluations faculty and students evaluations as something we are priming our faculty and students to watch for and think about. One more. So, we have other tools that we also use to train control resource utilization like payment models, managed care and so on. Has anyone ever studied whether the correlation between where a resident comes from and what medical students and their spending varies according to the environment in which they go? Other than this, these studies of residents, so they were actually studies of physicians looking at. Their practice patterns resembled the residency environment more than the current environment. Yeah, it would be interesting to see whether if you look at a bunch of positions varying environments within a given payment environment to understand how much it still plays out there or whether in fact there's a tremendous amount of homogenization that happens once people arrive and my guess anytime anyone's ever looked at any unit of analysis there's a lot of variations. So I'm guessing that we would continue to see individual level variation. I've looked at the folks in my own department there's huge individual variation in the same sort of practice setting in terms of resource utilization. People have looked at patients who moved and the intensity, you know, because people many doctors will say, well since patients asking me for all of these unnecessary things I want to have good scores it's linked to my salary, you know my payment my salary and so people looked at patients and when they moved the care they received resembles the practice pattern of that region not where they came from. So patients may be less of a driver's Now, we've been thinking about the clinician-patient relationship as this dyad but to your point in reality since the mid-1900s correct me if I'm wrong there's almost always some third party payer involved. We've done one study looking at simultaneously measuring the perspectives of these three different stakeholders we didn't ask the administrators and operations managers and the sort of people who think about the bottom line and they were the most likely to think physicians have a responsibility to be cost-conscious to incorporate costs in the daily practice and they saw far fewer drawbacks to cost-conscious care than either physicians or patients so these different stakeholders have different perspectives so how did we get to this place So looking backward for a moment this is a chart showing different sorts of payment models from fee-for-service on the left to capitated payments for an entire population on the right and the attendant risk of overuse on the one side and underuse on the other Early on fee-for-service was the predominant model it still is in many respects and around the 1980s here is recognized that healthcare costs are going up and at this point it's 10% of the GDP and it's already being called a crisis it's double that now it's still being called a crisis so there was this big interest in cost containment cost reduction so what happened? so Medicare created their diagnosis-related group system where they bundled payments for episodes of care in the hospital and there was this big movement toward HMOs which were managed by insurance companies and promised to control costs without passing along the financial risk to patients but they did that by using primary care providers as gatekeepers so you couldn't get access to testing or specialists without going through your primary care factor and there was this over its the approval utilization review process through the insurance company that was matched by that's a supply side intervention so forgive me if this is a big simplification but there were also demand side efforts underway including this famous study that looked at how patients utilize healthcare services when they have different skin in the game so you can see that patients in the purple here had access to care for free and they used more care and the patients in the white group had to pay 95% of the cost and they used less care and overall there were no huge differences in health outcomes between these two groups so there was this demand side I heard to have patients have some skin in the game now unfortunately patients when they have access to care they use more necessary and unnecessary care and when they have more skin in the game they use less unnecessary care and less unnecessary care so this isn't a perfect solution but this is the type of work that was happening at that time and sure enough there was a plateau that was contributed to a plateau in health care spending growth during that decade and even a reduction in out of pocket costs however this was not popular physicians lamented the loss of professional autonomy and having to get approval for everything they thought was right for their patient all the administrative hassle that came along with that and then this perception among clinicians and patients that insurance companies were rationing putting profit before the needs of patients and that led to a big erosion of trust and I think we still see that erosion now this is from a study looking at patient perspectives on evidence-based medicine and there's this kind of underlying currents of skepticism that many have is this information driven by research or by someone wanting to save money I think they're thinking about the whole hard calculations they don't want to pay out so we're still facing this erosion of trust around anything that might be smack of being intended to save costs so in the early 2000s professional societies like the AMA and others came out with statements about how physicians do need to individual patients comes first but that physicians also have this professional obligation to provide healthcare resources and in 2008 the healthcare community really rallied around the Institute for Healthcare Improvement Triple A which included costs which had dominated the conversation before but it also included costs in relation to patient experience of care and the quality of care population health outcomes and by considering costs in relation to quality from cost consciousness to a language that talked about value and the appropriateness of care and that's on a continuum I think you heard some of this from Dr. Levinson perhaps when she was here recently so overuse care of unnecessary ineffective and potentially harmful underuse of effective care and misuse where it's inappropriately used and appropriate use and this language seems to resonate a lot more with the healthcare community and gave rise to the choosing wisely campaign trying to bring this into the professional and public consciousness and if you look at clinicians 87% will say they talk to their patients about avoiding unnecessary tests but only 20% talk to their patients about costs so I think this illustrates how value and appropriateness of care is going to resonate more with physicians and other clinicians and patients the same way they get this idea that a doctor can recommend against a test or treatment if it's unlikely to be beneficial and that I can play role in reducing costs by not requesting unnecessary potentially harmful care and I think what makes this easy at first blush is that much of the conversation about overuse and misuse is in this square down here it's bad for the patient and it's bad for society so we can all agree not to do it but there's a lot of gray area here because these concepts exist for the continuum and so there's still a lot of situations in practice where it's going to be difficult to judge if this is something that's clearly overuse or appropriate care so where has that taken us now well we have this tryout of the payers I think we also need to step one step a little bit further back to talk about the policy makers there's been a shift in payment models from trying to reimburse based on the volume of care provided to the value of care provided and so the Affordable Care Act MACRA these are now they're built on top of that fee for service model that continues to be so common in our payment systems but it layers on this mandatory reporting for quality safety patient experience outcomes and then offers shared savings if costs come in below or shared widths if costs come in above so they're trying to link incentives to value reimbursement to value the DRG bundling system didn't use to include the physician fees those were added in 2016 and some of the more alternative payment models are moving toward the other new spectrum here so they're more of a capitated approach but you may at first thing well that sounds like those HMOs that nobody liked back in the 90s but these are going to be managed by care delivery groups not by insurance companies the idea being that they're in a better position to make those judgments about what's appropriate for patients and how they can care more efficiently these are the goals of this value based reimbursement strategy providing accountability promoting innovation improving quality and reducing costs that's that triple aim whether this will achieve the goal there's some debate concerns about playing to the game trying to perform well on one quality measure might lead you to perform worse on another or to triage out patients who are going to bring down their scores and worsen inequities of care it's expensive to measure all those quality and safety metrics but most or many agree that this is nevertheless the direction that you can continue to try to go is not perfect yet and the percentage payment is linked to these types of models which gradually increase over time and there's corresponding efforts to build health insurance programs that incentivize value too if I want to see my primary care provider incentivize care I can do that for free if I want to get cosmetic surgery or lift up my eyebrows I'm going to pay a lot more and that's built into my insurance so we've stepped back a little to look at payers and policy makers any questions at this point in the conversation it's not or comments I know you have a lot of questions add a little question my concern about these value based models and all the quality metrics is that the quality metrics are inadequately reflective of the experience of the small number of people in the system who experience the most complex episodes of care and in fact all the incentives are to do much much less for those people and in fact to do more for the people who actually don't need care but respond to the patient side of the actions surveys and everything else I just had a conference yesterday organized in Chicago about safety net providers and I even heard a speaker I won't even mention who the speaker was sort of politically sensitive but I would say I was dismayed that everyone of my peers was supported by how value based care was really being implemented and so you know you sort of said well there's a lot of agreement that this is happening I think what your slide showed was that it was growing it's growing I think there's agreement that the direction is right I'm not sure the implementation might be wrong so this is sort of like what I am convinced is that people making a whole big pile of money in health care agree that this is happening and that it's important and that managed care this is their business and I will add on top of that that the business of government is very often very closely tied to the business of health care business so if you're involved in administering public benefits, managed care is sort of your best because you can offload your own play responsibility for pretty much everything financial and political into another area so I guess that's kind of my push back but also sort of my question in fact is there broad enthusiasm for these approaches outside of payers and people making money out of it I heard from your first comment the answer may be it's very perhaps no I've seen some you know, proposals that we need to think about we need to focus on our most needy populations chronic, multiple chronic illnesses mental health and that our quality measures are not targeting the patients who need them the most so I've seen arguments to try to align our measurement being more strategic about that one of the most compelling things I've seen which I don't think I had in this version of the talk is when you plot health care spending compared to other developed countries we look so much higher but when you add spending on social services those other countries are right up there with us so there may be bigger questions we need to ask about where is the right place to invest our national dollars I was really happy to bring in say what he said about driving this and it seems that as a physician who's taking care of patients this seems so onerous having to just be watched everything you do with the assumption that you're going to commit fraud and this goes back to like the 90s when the costs were just going crazy because there are a lot of doctors who were just charging the highest rate for everything and just using the system but that became the common practice because they were encouraged to build the highest rate by administrators so people felt powerless and now basically we're all being punished for and this idea of always thinking about costs is just such a waste of time because what you really need to do is take care of the patient this is what the patient needs is what they tell me the cost of what it actually is going to come down to is really a secondary phenomenon and a lot of those costs are deeply inflated by people who are making tons of money on this I think it's time we address the elephant in the room which is the huge amounts of money that people are making including many doctors so it's time for us to perhaps make less money and get people out of there seeing this is the investment I mean people are making huge amounts of money on death and dying of our patients and it seems like basically we have a misalignment of incentives and interests that are not centered on patients the way they should be I mean yeah but making a chemical therapy move they make because it's just going to add so much waste and so much wasted documentation and time and money keeping track of all that nonsense but I don't understand why you're so excited about I'll show you that I've also heard that people from Minnesota say they're excited they might not actually be I think you've all raised some really excellent points and there is a slide showing the drivers of waste and how well a lot of the burden of documentation to be put on physicians and that frontline dyad the biggest drivers of waste live in other places that we need to think about in other ways so yeah probably a little bit picture question we don't have a similar one single cost structure for any of the other services in this country or anywhere so if you want to travel with a plane you can choose to be coach, business first class if I want to send an envelope it could be USPS, FedEx but now it feels like we're trying to create this one cost structure for the entire population is it even feasible or is it reasonable to do that why don't we give people different options so I'm just the economist in the front row have any thoughts about that well I'm not even sure it's true about planes I mean we're going to draw on the same plane and we're dyadic so that doesn't exactly work some people get bigger seats yeah that's true you know I think part of the complexity of all of this is that there's a societal interest in the health of everyone and that probably opposes a minimum we probably do have a tier to the reality if we admit it you know we're moving even closer to it now probably including in our locality that we weren't in the past complicated complicated and contentious do I have a somber Minnesota case so this is where we've been and I think the conversation just now highlights we're talking about payers we're talking about policy makers the complexity that surrounds that how something that sounds good in theory might really fall flat in its goal in practice or even be antithetical to what it's trying to achieve I think the things that he's written a great paper about eras re in medicine moving from all this measurements to more of a professionalism model that doesn't punish all the physicians for the few that are doing things fraudulently and irresponsibly and he raises this important point that anytime you're talking about value there's this question the elephant in the room of value from whose perspective is this the payer and the people profiting off of this model or is this the clinicians and their patients in health care because it's set up as a profession this sort of implication is that we professionals are in the best position to judge the value of their care but in other industries service industries and products excellence is in the eye of the consumer so I think that begs the question I mean there's a bigger question of whether payers or policy makers see eye to eye with what patients need and want but also whether we as clinicians and physicians see eye to eye with our patients I know as a neurologist you know at a tertiary referral center we get unusual things we do these big workups and get really excited to make a new security diagnosis but then at the end of the day what the patient really wants is to feel better to be able to hold their granddaughter to play their saxophone in their band and all of that energy around the diagnosis people care about knowing that information and what to expect on the line but it falls a little flat the excitement that's in the workroom when you're rounding can fall a little flat when you're at the bedside of the patient and when you think about how patients judge value what patients tell us is that they're referring value from the quality of their relationship with the clinician and the degree to which the care they receive makes them able to achieve their life goals and live in alignment with their priorities their ability to live life as normally as possible and this isn't always how we as doctors think about things patient-centered care I think can be taken to a whole new level and this idea of having respect for patients on their terms helps me understand why my grandpa is a farmer in Montana when his cardiologist told him he needed a pacemaker and a stimulator he said heck no why not sudden test and he says well the place where they're going to put that pacemaker I use that shoulder to open gates I do open gates that didn't make sense to me but that was really important to him and it wasn't until his cardiac condition that his ability to open gates that he was ready to think about that and a similar conversation with his brother who had a diagnosis of esophageal cancer I heard this every girl in Montana I quickly scrambled to try to get him an appointment with an oncologist at Mayo I didn't get you in next week and he said but it's harvest I said well you have cancer he said but it's harvest so there could be this mismatch and I think the same with evidence based medicine we look at these studies of populations that give results that are averages the patients are individuals they want to be seen as individuals not only as individuals but as individuals with a unique life story unique context people who think about health in different ways different ways that people in the U.S. conceptualize health capacity control physical well-being psychosocial well-being and they might prioritize health in different ways relative to other dimensions of human worship so for my grandpa deriving a lot of meaning and purpose from being able to work on a farm and my uncle to finish harvest was more important to them to optimize their physical health which is the land that I was bringing to my conversations so if we look toward the future I think we need to ask some of these hard questions about what my colleague Dr. Victor Montori says do we care more about value than we value caring? Have we gotten this order backwards and what does this mean for the physician-patient relationship you know in the olden days was more holistic some patients wanted a more autonomous relationship there's a smooth to share decision-making and more equitable that requires a lot more transparency around data than we have right now well maybe a collaborative model where we recognize that each brings their own expertise physician-supportive of a patient proactive to create this understanding together and recognize a care plan that is right for that person's life one of my jobs is quality chairs in the department neurologies to read our patient experience survey comments this is one I came across that I think highlights this idea she should lose that I'm a doctor and you're not an attitude her talents speak for themselves I wasn't there to dispute anything but it's my life, my body I live with it every day I think we need to think about patients as being experts in their own life we're experts in medicine and that combination can really take patient-centered care and what we mean when we talk about value in a more patient-centered direction and there's movements on the patient side of things the society for participatory medicine talks about being patients and I think any of you who are in practice will recognize this idea equipped, enabled, empowered, engaged evaluating patients who are looking you up before they come to see you to see what your stories are and you're not going to be treated as a patient now that doesn't mean that that collaborative or participatory model is the right for every setting but I think we're going to see more of that this is a five-step framework for promoting value and clinical encounters taking it all the way back down to that clinician-patient dyad and again with understanding the benefits, harms and well as it comes so that your point about we don't even have access to that data there's a long way we need to go to even do step one but it's worth it needs to happen and then having what we call less is more conversations but not framing it as appeals to save societal resources but using more of that choosing wisely lens of this is unnecessary care that you don't need to be harmed you and this is an infographic we've created out of some of Dr. Aurora's work and others about how to have these less is more conversations with students listening to where the patient's coming from making it clear that you're on their side explaining your reasoning without appeals to society because that comes across and rationing or putting costs first and then having a clear plan for follow which is part of that relationship using interventions and care settings that will achieve the tripling basically maximize the benefits minimize harms and reduce costs and then this important part of customizing care to the individual in front of you that can be done using decision aids and I know there are many places that you can go to access these we've created some at the Mayo Clinic as well you can really see when you watch the videos how these change interactions be much more collaborative this is one that I like it's designed for patients with multiple chronic illnesses to think more broadly about what areas of their life are a satisfaction or a burden or both and how maybe the care we're providing is aggravating the problem versus helping it and try to have those more customized individualized conversations about what's high values for that person and their life we haven't talked a lot about out of pocket costs those are going up to to your point about you don't know what the cost is to society much less the cost to a patient you can screen for financial harm using questions like are you worried about how your care will be paid for do you sometimes skip medications or cut back because of the cost and that will help crime you to pick up these concerns patients are sometimes reluctant to bring it up but when you ask many of them would like to talk about it so we can help with that and then finally not forgetting about those systems level opportunities to create a more high value system that's focused on the needs of the patient and to your point about sources of waste you know the physicians if I look at this list which of the ones fits out to me is where I can have the most immediate impact is that overuse low value care but the biggest drivers there are administrative complexity from so many different models and all of the work that goes into that pricing failures that's a whole complex issue of its own and then lack of care delivery and coordination which is really where some of the systems energy could be focused what's a pricing failure so that's how a price is so look for example at multiple sclerosis drugs there's you know 15 or so of them and the cost even the ones that have been around for 20 years that's a success for the people who are failure for whose perspective yeah I actually learned the other day that the government pays more for the like 15 MS drugs three times more than all of your models I mean I kind of could have started perspective to me around this pricing issue or pricing success I suppose if you ask someone else now we've also asked medical students you know there's an interest in getting students engaged in promoting value and when you ask them what they're interested in doing they tend to rate patient care things that's the blue bars hires they're more interested in that than systems things that's the red it's just harder to kind of get your head around the system what it means to improve a system so helping I think as educators and role models we can help our learners really see what the end who are all here for right it's the patients and when you're working on a quality improvement project or a systems project this is you know that the end beneficiary of that effort and hopefully that will help bolster interest in engagement so that someday we have a system that is more centered around the patient it seems to me that some of the problems it lies in a couple of the slide you showed before I'm not a sociologist but I study some of this 10% of the cost of medicine is to go from right so that's the cost of medicine but who is supposed to prevent it from second 10% of them is of the malpractice not just lawyers say it's 2 to 3% but it is 10% when we call unnecessary questions a lot of MRI that they do one after each other and that's estimated to be the cost 10% of that is waste in other words people have medicine they don't use if you take the medicine that some of the nurses have collected you could give it for another sitting and do that so 10% of the cost are social illness that it comes to the cost of medicine now people not different from animal behave the way that environment imposes something so if the cost is very high then the people charge very more I could say that if you cancel all MRI and you put it CT scan the cost of CT will go up as much as MRI if you just only do an x-ray and nothing else the cost is going just as much because the people have to pay for their expenses now when I was the president here we had one lawyer another real lawyer a secretary on the fifth floor in order to fill out charge somebody wants it now we have a corridor okay department of surgery I was a secretary one for the chief of American houses and the other one for the whole we have a corridor for the people because they have to be with insurance so the cost is very high that's what bring it that's why you could get an MRI scan in another country for $1,000 and read for you but here is $7,000 and $2,000 for reading so you cannot separate saving and all these good things that you take from our social illnesses that's a very important point and if you look at you know drivers of overuse when it comes you know physicians will talk about patients asking for this test but concern about no practice is right up there and that's not teased out on the table like this and I was shocked too talking to one of our leaders in the quality something like 15 million dollars just on the measures um I had my jaw dropped when I heard that number for an organization to collect and report all of that so it's a complicated issue and as clinicians and patients we're embedded in the middle of that so trying to find tools to navigate the system as best we can while advocating for change and broader ways this morning we our resident presented two bullet injuries to the brain now these patients require cost a lot of they don't have insurance so because the bullet and all is a number bullet the number is 100 times more than many other countries that is a social illness that we cannot calculate and then we tell someone okay you don't have an MRI and I will see a nurse there maybe we need to be thinking not just about physical loss I think you have to be a economist and sociologist and all get together in order to come something that will follow up to that I just want to bring up another idea about the patient because the way if you look at really carefully is a kind of pain sight perspective after things happen then you look back saying oh this shouldn't happen because it's ways you didn't use that but if we look forward as a doctor as a physician when prescribing drugs or assignments examinations you should have a reason to do that you're not thinking oh it's a waste and then I do this no it's the way you look forward but you look back and you know it's waste so I don't think that really works this is one of the idea of waste is the kind of thing that you look pain sight perspective and the other thing is there was this live showing that expanding American healthcare is really exploding like a hail going out to work but if you look at the S&P 500 the stock market index is going the same way why that? because of the economy the Federal Reserve are giving out money, giving way money to this economy the economy is going up forward so we have more money so our spending is increasing and because people are able to pay their medical medical costs either because the government insurance or private insurance so doctors can prescribe these drugs and they can do these donations so the spending are increasing the same speed as S&P 500 is going up because of the economy if the economy is not going up like those poor countries or like the European countries you may just mention their economy is going like flat then their healthcare expanding if you take a look into it aren't just like flat because healthcare spending is part of our economy it goes outward we is our economy so this is not if you see this in a bigger picture and there is another thing I want to mention about your talk to the patient is that there is an old economic joke saying that there is a farmer that wants to sell rice to a customer and they have did exist coffee because the farmer wants to make the price higher and the customer wants to make the price lower and they want to make the deal done if they think too much about other the other one then the deal will not be done let's think about that if the farmer wants to your student do too hard I want to give you free lunch and the student think oh your farmer you making this too hard I really want you to I really want to give you more money then they will not make the deal done so as a doctor and patient we need to make give good help not making the cost lower just like Dr. Daniel said the main target should be give good help just like the farmer and the customer make the deal done I want to rice I want the money to go on keep a high price on these devices so the economy can work otherwise the deal will not be done because I think maybe that's why I smile when I think about value because I see value is headed in the right direction from just thinking about cost because at least it's a more synthetic term it's bringing the quality and the safety the patient experience the timeliness the equity and the efficiency of care together relative to cost and not just cost but cost over time so by bringing those together it lets us at least in theory focus more on what's the right thing to do what we need to do and what's for instead of what's the cost of the patient it seems like you're using value in a couple different ways here and in one way it's tied to cost but in other ways it's not it's tied to what the patient was wanting and the benefit and so I think it's very confusing well so they talk about value as quality over cost some people do some people do that's that common way of thinking about value even in that frame quality has different dimensions of which patient-centered care is one and that's lost in our our discourse today is really an industrial economic discourse that talks about value is really thinking about dollar science and I think also you're thinking about being on the side of the patient I think medical students when they get in they actually are on the side of the patients and I think pretty soon after they become residents they're no longer on the same side and I think that they switch they switch sides because the patient becomes this person that you want to get out of the hospital and I think that that's inculcated in residency and I think it continues relationship I think that raises another really important point about how we need a richer understanding of quality that elevates the patient perspective beyond where it is today and we need a more nuanced understanding of the cost that's not just money there's a cost to me as a resident being on call admitting all these people and there's a cost to patients having to disrupt their lives and coming to see us time and convenience, anxiety financial taxes and all of those things so thinking about quality in a more multi-dimensional way thinking about cost in a more nuanced way thinking about maybe we just need to completely shift our discourse my colleague Dr. Montori says is healthcare an industrial enterprise where we're mobilizing we're focusing on care to achieve our industrial needs or should we be thinking about care as a goal that we're mobilizing all our needs toward and do we need to rethink our whole language maybe value is so steeped in the money that it's lost its ability to serve that purpose and maybe thinking more about something like kind and careful care is what he has proposed doesn't tolerate hate doesn't tolerate waste it's kind and careful to the person in front of us so that may be a whole change of discourse maybe what's required to navigate for question me the focus on quality if that's what we need to move but that also requires measurement time and costly measurement of outcome and I think it's just to kind of throw that to you don't want to do, you don't want to miss that extra time or that extra money into this but we already spend a lot of time working on billing for services the cost side of care it seems disproportionate we're willing to invest the time when it's going to reimburse us but maybe not when it's good I'd like to ask a question and then one more from the audience well thank you so I shared just before your talk that I've recently seen this documentary about the Mayo Clinic made by Ken Burns and anyone who hasn't seen this I really recommend it I know it's officially part of the American Experience series or not but it's really extraordinary because the Mayo Clinic Mayo Clinic's history is a referral center people coming from very far away with problems they feel have gotten not adequately addressed wherever they are and I would imagine often looking for a very deep dive into a question and what I'm curious about is as you train medical students and residents in that environment and as you treat both people from the community and people who come from the opposite side of the world how does the value discussion feed into the discussion about the difference between those two sets of patients does everyone get the same treatment or do people get different treatments because of who they are or where they come from or what they want so the the truism that circulates from the Mayo Clinic said by one of our sisters who helped found Mayo Clinic together with the Mayo Brothers and it's no money, no mission, no mission, no money so a lot of times when these debates and tensions come up somebody will say that quote and will think about what does that mean in this particular instance in terms of trying to serve different populations I think the cost that's at the front of my mind when I am taking care of patients is time you know somebody's traveled a long ways away they're paying for a hotel a dog center, a lady's center airline tickets time away from work and they're looking for answers so the cost that I have in mind is less so money and more so time whereas if we have community patients that lens is different because they would write down the streets and it's easier to provide longitudinal follow up and not rely on tests which don't have the luxury of that sort of time so I think that illustrates how and I try to like make sure that I make that difference explicit for the trainees because I found doing all this destination medical center care I had to sort of like flip a switch and have a different mindset in the community practice because that would be an undue burden to those folks whereas it was maybe a high value to these folks so I didn't think of it I don't think of it so much as a tear as thinking about costs in a different way and those are the kind of complicated tradeoffs that we make as clinicians and patients yet another example which as an economist I was pointing out is fascinating because people pay for their own time in their own air ticket but they don't pay for their own tests so it's this interesting societal personal experience and most of them have insurance yeah but that's what I mean you're happy to go there without insurance you are now trauma centered I'm not sure not so many people go there with bullets and with the injury and the car you can see the person who fell in the tractor yeah any last questions listen, thank you so much what a wonderful talk