ACR Bulletin

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Cost Discussions: What Do Patients and Families Want?

High-quality, high-value healthcare should prioritize communication, coordination, and access.
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One way to reduce cost is to reduce the volume of imaging. However, any attempts to do so must ensure that access to appropriate, high-quality imaging is maintained

March 30, 2019
Policymakers are committed to evaluating physicians on cost performance. Cost is an integral component of the Quality Payment Program and it will affect all clinicians and their organizations. However, has anyone asked patients, families, and caregivers what they need as it relates to cost? Someone has, and the results are interesting.

A number of ACR representatives participated on one of several CMS subcommittees tasked with the construction of clinical episodes of care to evaluate clinical cost performance. For example, I co-chaired two subcommittees: one on lower extremity revascularization and another on hemodialysis access creation. To inform actions, the supporting CMS contractor gathered a Patient and Family Committee (PFC)* to hear its perspectives on clinician cost performance.

The PFC acknowledged that cost control is important to identify unnecessary or wasteful Medicare spending. However, the PFC was not willing to compromise on quality under cost-related discussions. The PFC indicated “that cost-performance information would only be meaningful to them if presented alongside information about quality of care.” In other words, the PFC was willing to accept cost metrics only if they were tied to quality. Further, “they would consider choosing a low-cost clinician if they also provided average or high-quality care.” The PFC further stressed that the goals of high-quality and high-value healthcare should prioritize communication, coordination, and access.

According to the PFC, any efforts to reduce cost must increase and protect communication. The PFC members want time with their providers, allowing them to receive information and ask questions to make informed decisions. Greater coordination of care is a related want. The PFC especially desires “coordination across clinicians and facilities (especially after a hospital stay).” During both the communication and coordination discussions, the PFC noted that medications are particularly important, “including an explanation of how to take each one and their purpose.”

What does this mean to us? Imaging results are an important component of communication, coordination, and decision-making. This affords us the opportunity to improve our communication of imaging results. For instance, we can deliver those results in a manner that is understandable and actionable for the patient.

One could easily extrapolate their wants on medications to understand their wants on imaging. If they want an explanation of their medications, might they want the same for imaging? What can PFC members expect from their imaging encounters? Who will communicate the results and decide on therapies and next steps? For instance, what follow-up imaging or therapies are necessary after a hospital admission, ER visit, or clinic visit? And why? Interoperability also has a role in these discussions. It makes sense that patients would expect their imaging to be accessible across different sites — and not through a CD that they carry themselves, but through a seamless interface.

The PFC did not discuss price transparency, which is presumably not only a related expectation of patients and families but also the focus of policymakers at multiple levels. Hence, this should be on our radar.

This brings us back to quality. One way to reduce cost is to reduce the volume of imaging. However, any attempts to do so must ensure that access to appropriate, high-quality imaging is maintained. The imaging clinical decision support mandate, also known as the Medicare Appropriate Use Criteria program, is a means to achieving the goal of decreasing inappropriate imaging while encouraging appropriate imaging. It is also a means to providing a platform for communication involving the radiologist, ordering physician, patient, and family. Place-of-service discussions are also important to cost control. Systematically moving from one site of service to a lower-cost site may be acceptable. However, this must occur only when the quality of the site to which care is steered is validated.

“Quality is our image” is the ACR’s tagline, and it applies at multiple levels described by the PFC. Quality patient-centered care includes ensuring the proper studies are performed at the right time. Our ability to effectively communicate those results to all stakeholders involved in care coordination is an important opportunity. Patients expect it.

* The Patient and Family Committee is not to be confused with the ACR’s Commission on Patient- and Family-Centered Care.
Author Ezequiel Silva III, MD, FACR  Chair, ACR Commission on Economics