Back to school: Teaching the next generation of cost-conscious physicians

Reimbursement cuts, radiology benefits management, accountable care organizations—the list of strategies to control soaring U.S. healthcare costs is long and growing. But perhaps to truly control costs, healthcare needs to revisit where physicians' careers begin: medical school.

That’s the point made by three professors at the Mayo Clinic in Rochester, Minn., in an article they wrote for Academic Medicine in response to that journal’s 2011 Question of the Year.

The question asked what improvements in medical education will lead to better health for individuals and populations, and for Frederic W. Hafferty, PhD; Michael Brennan, MD; and Wojciech Pawlina, MD, the answer was to teach medical students to consider the burden of treatments they provide from a financial perspective.

“I don’t see any reason why students and physicians should not, in principle, have a realistic understanding of what financial burden is being generated for both patients and society as a whole,” said Hafferty in an interview.

Their article provides numerous suggestions for completely restructuring medical school to train more financially prudent providers.

“We propose, therefore, a training process organized not around disciplines, organ systems, diseases or clinical problems, but around cost,” wrote the authors.

Changes would start right at admissions. All medical school applicants, the authors asserted, should be required to show proficiencies in economics and healthcare economics, in particular, in addition to organic chemistry, physiology and other assorted scientific disciplines studied by premed undergraduates. Potential students also would have to document community service experience in clinic business offices or other sites where they can see how medical charges are processed.

“Admissions requirements and admissions processes are a huge source of implicit messages about what’s important,” said Hafferty. “One should be able to look at what medical schools ask for in terms of application materials and requirements as a statement of those meta-values.”

By pushing back the teaching of “cost-consciousness” or focusing on it exclusively as a topic for continuing medical education, the message is that it’s merely an add-on, something to learn after all the “really important stuff,” said Hafferty. “I think that’s a huge mistake.”

The first two months of medical school would be devoted to the economics of care under the authors’ medical school model. Students would hear from cost experts as well as patients and members of the public who are continuously struggling with their medical bills. As students build competency, they would meet with patients upon discharge to explain all charges.

“There will be no traditional ‘patient care’ contact until students are fully able to decode and explain the highly cryptic billing statements that encumber patients,” wrote the authors.

Once students begin the biomedical side of their training, they would be expected to add cost explanations to explanations of diagnoses and treatment options.

Hafferty said that while courses on healthcare economics are taught at medical schools, there aren’t many emphasizing it, let alone keeping students from seeing patients until they can interpret a bill for them, but the question the authors wanted to raise was, “Why not?”

Having providers control their own costs based on the training they received would seem to be a more palatable option for physicians compared with top-down control from regulatory agencies. However, the authors noted that it's difficult for any occupation to self-regulate when there’s little understanding of the issue, in this case the cost of care.

“The first step to self-regulation would be self-knowledge, but if you’re going turn regulation over to somebody else, then they’re going do it,” said Hafferty. “If you’re going to have a seat at the cost table, you better know what things cost. You can’t just sit there and listen to the proverbial ‘other guy.’”

Paraphrasing former Speaker of the House Tip O’Neill who famously said, “All politics is local,” Hafferty said that in the end, all healthcare is local, too. It’s about the relationship between providers and patients, and any regulation that happens away from that interaction doesn’t bode well for controlling costs.

There are certainly reasons that schools couldn’t expand the amount of cost-consciousness education they provide–there are only so many hours in the curriculum, after all–but Hafferty said that something must be done to start lowering costs. “If we don’t get a handle on this, the only people that are going to be able to afford healthcare are the 1 percent.”