1. Less is More 2.0: Implementing the High Value Care Curriculum
Jessica Dine, KeryLyn Gwisdalla, Darilyn Moyer, Jason Post and Sara Wallach

2. Disclosures
Darilyn Moyer ACP Governor SE Pennsylvania and Chair Elect Board Of Governors Sara Wallach-Pfizer Stock

3. Learning Objectives
Describe the AAIM/ACP High Value Care Curriculum Ver. 2.0
Practice a small group activity from the curriculum
Identify how this material should be integrated into existing program curriculum
Practice using tools to assess milestones related to HVC

4. Workshop Outline Introduction and overview of curriculum
Practice small group case and activity from the curriculum
Small discussion group on best practices in curricular implementation
Describe the curriculum toolbox
Small group activity practicing using the assessment tools
Wrap-up

5. High Value Care Definition
Care that balances clinical benefit with cost and harms with the goal of improving patient outcomes

6. Quick Poll and Group Feedback
Are you aware of the AAIM/ACP High Value Care Curriculum?
Has it been incorporated into your program?
What worked? What didn’t work?

7. What is the problem?1
We spend too much on healthcare – 17% of U.S. GDP
Since 1970, healthcare spending is rising 2.4% faster than GDP
Estimated $700 billion of “healthcare waste” annually
Physicians responsible for 87% of wasteful spending
Within the current healthcare system, no real disincentive to curb providers’ ordering practices
Physicians must lead in addressing these problems – and we are! (Choosing Wisely campaign)
Trainees (YOU) must be at the front lines
The New England Healthcare Institute (NEHI) has defined waste in healthcare as “Healthcare spending that can be eliminated without reducing the quality of care.”

8. Healthcare Waste2
Estimated $700 Billion of “Healthcare waste” annually
$ B in “Unwarranted use”
$75-100B in “Provider inefficiency and errors”
$25-50B in “Lack of care coordination”

9. Ordering more services3…
Tests
Imaging
Two areas of greatest expenditures and most rapid growth: imaging and tests

10. Shifting focus
Get physicians to understand and focus on health care value Before using a test or treatment, they should consider the potential benefits and potential harms and costs. More care is better care High value, customized care is better care

11. IM Resident Curriculum 2.0 Overview
FREE, off-the-shelf curriculum
Based on a simple, step-wise framework
Six, one-hour presentations
Small group activities involving actual cases and bills to engage learners
Facilitator’s guide accompanies each presentation to help faculty prepare
Program Director’s toolbox

12. Curriculum Topics and Cases
Presentation #1 Eliminating Healthcare Waste and Over-ordering of Tests
Headache, heart failure, deep venous thrombosis
Presentation #2 Healthcare Costs and Payment Models
Appendicitis, sports injury, osteomyelitis
Presentation #3 Utilizing Biostatistics in Diagnosis, Screening and Prevention
Chest pain, periodic health examination, chemoprevention
Presentation #4 High Value Medication Prescribing
Seasonal allergies, discharge medication reconciliation
Presentation #5 Overcoming Barriers to High Value Care
Low back pain, URI, septic joint
Presentation #6 (Local) High Value Quality Improvement Projects

13. Presentation 1: Eliminating Healthcare Waste and Over-ordering of Tests
Define and emphasize importance of HVC
Introduce 5 step model
Introduce Choosing Wisely Campaign
Cases: Headache, heart failure, deep venous thrombosis

14. Steps Toward High Value Care4
Step one: Understand the benefits, harms, and relative costs of the interventions that you are considering
Step two: Decrease or eliminate the use of interventions that provide no benefits and/or may be harmful
Step three: Choose interventions and care settings that maximize benefits, minimize harms, and reduce costs (using comparative-effectiveness and cost-effectiveness data)
Step four: Customize a care plan with the patient that incorporates their values and addresses their concerns
Step five: Identify system level opportunities to improve outcomes, minimize harms, and reduce healthcare waste

15. Presentation 2: Healthcare Costs and Payment Models
Explain basics of health insurance and coverage
Weigh impact of insurance on health care access
Discuss how reimbursement models can affect HVC
Cases: Appendicitis, sports injury, osteomyelitis

16. Presentation 3: Utilizing Biostatistics in Diagnosis, Screening and Prevention
Review basics of statistical concepts
Explore benefits and harms of routine screening
Use tools to identify high value preventive care
Cases: Chest pain, periodic health examination, chemoprevention

17. Presentation 4: High Value Medication Prescribing
Explore comparative costs of medications (generic vs. non-generic)
Identify medication cost as a barrier to adherence
Identify resources to assist patients with medication costs
Cases: Seasonal allergies, discharge medication reconciliation

18. Presentation 5: Overcoming Barriers to High Value Care
Weight efficacy and safety of medical interventions to avoid inappropriate use/harm
Practice negotiating a care plan with patients
Frame an effective consult question
Cases: Low back pain, URI, septic joint

19. Presentation 6: High Value Quality Improvement
Identify QI resources in your institution
Involve residents in local safety and quality programs
Design a project to improve value in the delivery of patient care

20. Program Director’s Toolbox
Resident survey to measure curricular effectiveness
Tools to help faculty and program directors assess resident competence in high value care milestones
Sample local high value care quality improvement projects- reports, abstracts, posters, slide decks etc…

21. Curriculum Dissemination
The curriculum has been downloaded over 13,350 times since July 2012
Over 50% of program directors surveyed have implemented some component of the curriculum to date
54 programs report the initiation of local high value quality improvement projects from the curriculum

22. Resident Comments on Specific Modules
“It was brief and to the point; easy to understand”
“Bringing more attention to the insurance issues of patients”
“I particularly enjoyed the case scenarios”
“The presentation helped us to know how to cut down on prescription costs and still prescribe equally effective drugs”
“It is a very important topic that needs to be understood because this can really help our patients. The presentation is good, concise and informative”
“Real life examples help put the cost of brand name drugs in proper perspective”

23. Curriculum Small Group Activity
Divide into 4 small groups
Two groups will perform – DVT bill group activity
Two groups discuss “best practices” in curriculum implementation
Identify a group leader to report back:
For the case
Provide a one line summary of the case
Describe the interactive activity
Reflect on the case/activity-Was it helpful? Would you use it in your program?

24. Case #3: DVT – A tale of two thrombi
Management of DVT
Two patients in an ambulatory setting were suspected to have a DVT
One of the patients was sent to the emergency department and hospitalized for management of the DVT
The other patient was managed as an outpatient
Let’s compare costs…
Have residents look at the handouts provided for outpatient and inpatient bills
Elicit for whiteboard: What are the major differences in cost between the two scenarios? Nursing costs and the per diem overnight stay costs are major inpatient costs, also unnecessary services like PT evaluation, extra labs that are often checked as part of a routine “admission order” set

25. Inpatient Bill
Semi-Private Bed x 5 days
ABO
BNP
ECG
PTx 4
Portable CXR
PTT x 13
CT Chest with Contrast
D-Dimer
Sono Duplex Lower Extr Veins Bilaterally
CBC with diff x 5
Acetaminophen x multiple
ABG
Warfarin
Troponin x 3
Heparin 0.45% NACL 25,000 units/liter x multiple
BMP x 5
Echocardiogram
Hepatic Function
PT Evaluation
Total

26. Inpatient Bill
Semi-Private Bed x 5 days
$16,250.00
ABO
$26.46
BNP
$233.73
ECG
$206.02
PTx 4 ($34.35)
$137.40
Portable CXR
$409.61
PTT x 13 ($54.02)
$702.26
CT Chest with Contrast $
D-Dimer
$83.79
Sono Duplex Lower Extr Veins Bilaterally $
CBC with diff x 5
$168.30
Acetaminophen x multiple ($0.10)
ABG
$308.97
Warfarin ($0.14)
Troponin x 3
$549.03
Heparin 0.45% NACL 25,000 units/liter x multiple ($20.25)
BMP x 5 ($60.35)
$301.75
Echocardiogram $
Hepatic Function
$69.43
PT Evaluation
$319.09
Total
$ 24,518.57

27. Outpatient Bill Duplex scan extreme veins: complete bilateral study
Office visit established patient, level 4
CBC
CMP
Prothrombin Time x 4
Warfarin (30 days of 5 mg)
LMWH (10 syringes, 80mg each)
Total

28. Outpatient Bill Duplex scan extreme veins: complete bilateral study$
Office visit established patient, level 4 $
CBC $
CMP $
Prothrombin Time x 4 (34.35) $
Warfarin (30 days of 5 mg) $
LMWH (10 syringes, 80mg each) $
Total $

29. Cost Comparison Total Inpatient Cost Total Outpatient Cost $ 24,518.57$
- Cost difference of $ 22,484.69

30. Assessing HVC Milestones
Program Director’s Toolbox
Impact survey
Relevant milestones
Resident assessment tools
Small group activity

31. Program Director’s Toolbox
Resident survey to measure curricular effectiveness
Tools to help faculty and program directors assess resident competence in high value care milestones
Sample local high value care quality improvement projects- reports, abstracts, posters, slide decks etc…

32. HVC Curriculum Impact Survey
Retrospective survey
17 items
Assessing the impact of the curriculum on relevant behavior, culture and knowledge
Takes 5 to 10 minutes to complete

33. HVC Curriculum Impact Survey
1. How likely are you to do each of the following since participating in the high value care curriculum?
Discuss the risks and benefits of tests you order for patients with your attending.
Incorporate potential costs to the patient when ordering tests.
Discuss the costs to the health care system when ordering tests.
Weigh the risks, benefits, patient preference and costs when ordering tests.
Order unnecessary tests and treatments because they were requested by patients.
Options are: much less likely, less likely, unchanged, more likely, much more likely

35. Assessing HVC Milestones
Competency
Sub-Competency
Reporting Milestone
Patient Care
PC1(gathers and synthesizes information)
Effectively uses history and physical examination skills to minimize the need for further diagnostic testing.
Medical Knowledge
MK2(diagnostic testing and procedures)
Interprets complex diagnostic tests accurately.
Systems Based Practice
SBP3 (cost-effective care)
Consistently works to address patient specific barriers to cost-effective care.

36. Assessing HVC Milestones
Competency
Sub-Competency
Reporting Milestone
Practice Based Learning and Improvement
PBLI2 (performance audit)
Analyzes own clinical performance data and actively works to improve performance.
Professionalism
PROF3 (responds to patient’s unique needs)
Recognizes and accounts for the unique characteristics and needs of the patient/caregiver.
Interpersonal and Communication Skills
ICS1 (communicates effectively)
Identifies and incorporates patient preference in shared decision making across a wide variety of patient care conversations.

37. Assessing HVC Milestones
Resident assessment tools
Educational prescription
Audit and feedback
Milestones

38. Educational prescription

39. Educational prescription

40. Audit and feedback
Have learner identify a patient whose care they were involved in (either inpatient or outpatient)
Ask learner to estimate total cost/charge for patient’s care
Provide learner with itemized bill, or access to system to procure this data
Give learner time to review all charges/costs involved in this patient’s episode of care
Learner exercise/reflection

42. Assessing High Value Care Milestones
Divide into 3 small groups
Choose one of the resident assessment tools from the PD Toolbox (educational prescription, audit and feedback, milestones)
Identify a group leader to report back:
Describe the tool you used
How well did the tool work?
How do you envision using the tool in your program?
What additional tools might be helpful?

43. Best Practices Activity
Each group will discuss implementation of
curriculum into individual program
What barriers will you encounter?
What adjustments do you anticipate?
Assign a group leader to report

44. Summary and Wrap-up
AAIM/ACP has developed a FREE six hour curriculum to encourage residents and faculty to practice high value care
Curricular tool box to help assess the high value care milestones and incorporate the framework into daily work flow
Let’s work together to motivate faculty and trainees to eliminate health care waste while improving outcomes

45. References
Sager A, Socolar D. Health Costs Absorb One-Quarter of Economic Growth, Boston: Health Reform Program, Boston University School of Public Health; 2005.
Thomas Reuters. Where can $700 billion in waste be cut annually from the U.S Health Care system? October, 2009.
Medicare Payment Advisory Commission Data Book. "Healthcare Spending and the Medicare Program“; 2012.
Adapted from Owens, D. Ann Intern Med. 2011;154: