Can New Training Efforts Rein in Health Care Costs?
Swati DiDonato, MD, MBA
When Swati DiDonato, MD, MBA, accompanies medical trainees on their morning rounds at Stanford Hospital to review admitted patients’ statuses and plans, she finds herself asking the same question again and again: Will that test (or medicine, or therapy) really improve the patient’s overall health and well-being? Is it necessary?
Over recent decades, health care costs in the United States have risen dramatically. Some of this increase is due to administrative costs and the complexity of the healthcare system, and some of it is due to an aging population and increases in chronic illnesses. But a part of the increase can also be attributed to how medicine is practiced — which tests or treatments doctors use for their patients.
DiDonato, a clinical assistant professor of hospital medicine, thinks clinicians can benefit from dedicated training in “value-based care.” Value-based care embraces the idea of prioritizing tests, procedures, and treatments that are likely to improve the quality of care that the patient receives, rather than turning to many tests or interventions right off the bat. It emphasizes the use of drugs and devices most probable to increase a patient’s quality of life or life span.
"Ultimately, by embracing the practice of value-based care, we can better serve our patients and our community.”
– Swati DiDonato, MD, MBA
“Value-based care is a big topic right now because of the rising and unsustainable costs of health care in the U.S. that make it challenging to provide equitable and sustainable care for all Americans,” says DiDonato. “But there’s really a lack of centralized information and provider education on this topic. Ultimately, by embracing the practice of value-based care, we can better serve our patients and our community.”
To that end, DiDonato and Audra Horomanski, MD, a clinical assistant professor of immunology/rheumatology, have developed an introductory course known as the Stanford Value-Based Care Academy. Through a series of six lessons — all of which can be used for Continuing Medical Education (CME) credits — clinicians learn what it means to practice value-based care and how they can integrate it into their decision-making and conversations with patients. The course, though, is just one of the ways that DiDonato is encouraging value-based medicine at Stanford.
A Convergence of Medicine and Business
Thinking about the practice of medicine from a business perspective isn’t new to DiDonato. Her interest traces all the way back to her undergraduate days, when she was the editor in chief of the Yale Journal of Medicine and Law and a research assistant on a large project evaluating the impact of health care reforms on patient outcomes. During this time, DiDonato developed a passion for policies — at the federal, local, or hospital level — that can both help patients and streamline hospital workflows.
Then DiDonato completed Stanford’s dual-degree MD/MBA program — a five-year curriculum that lets students study both medicine and business. Throughout that time, as well as during the Stanford residency in internal medicine that followed, DiDonato became intimately familiar with how individual clinicians can help improve the quality and safety
of health care at Stanford by volunteering on working groups and councils, carrying out research on patient outcomes, and stepping up to leadership positions. With support from a Medical Scholars Research Fellowship, she studied how a patient’s demographics and insurance coverage impact the type of prostate cancer surgery they receive. She also led a project asking whether a new electronic health record system changed how patients in the hospital fared.
“As doctors, we have unique insight into the challenges that our patients face,” says DiDonato. “I think we’re going to keep seeing changes to medicine happening from the government and insurance side, and it’s important to have doctors who can advocate for our patients and help shape and implement these policy changes.”
During her training, DiDonato also led the Stanford Resident Safety Council, a group with the goal of developing new, systemic solutions to improve the quality and safety of patient care at Stanford. The group worked on projects such as the effective rollout of Voalte, a new communication tool for Stanford providers that lets them communicate through an encrypted smartphone app, as well as new patient education materials on drug side effects. These kinds of projects can improve health care by reducing medical errors and miscommunications.
Today, as a junior faculty member, DiDonato helps lead that same Resident Safety Council, as the associate program director. She also serves as a career adviser for students in the MD/MBA program.
“I really want to empower our trainees so that when they see issues or opportunities for improvement here at Stanford, they have the tool kits and resources to take things to the next level,” says DiDonato.
Teaching medical trainees how to think like a businessperson is one way to encourage systemic change in healthcare...But getting more senior physicians to think and act in new ways is paramount as well.
A New Curriculum
Teaching medical trainees how to think like a businessperson is one way to encourage systemic change in healthcare — over the coming years, it can lead to more junior faculty like DiDonato, who are inspired and equipped to make a difference. But getting more senior physicians to think and act in new ways is paramount as well, DiDonato says. That’s why she began working with Horomanski on the new CME course, with encouragement from General Medicine Section Chief Jeffrey Chi, MD, clinical associate professor of hospital medicine, and Hospital Medicine Division Chief Neera Ahuja, MD, clinical professor of medicine.
Just like her morning rounds lectures, the course that DiDonato developed aims to make doctors pause and think twice before they order a test or drug.
“We provide examples of what it looks like to use evidence-based guidelines and clinical pathways to guide the ordering of different tests and procedures,” says DiDonato.
The final lesson in the course focuses on how to talk to patients about value-based care. When a patient requests a particular test or drug, for instance, clinicians can struggle to communicate with the patient about why it’s not needed.
Initially, the Stanford Value-Based Care Academy is rolling out the virtual course for faculty members in the Department of Medicine. But DiDonato and Horomanski plan to adapt it for other departments, as well as medical students, residents, and fellows at Stanford. They’re also developing an in-person version of the course, in which staff of a given division can participate together, brainstorming how they can apply value-based care in their own day-to-day practices.
DiDonato hopes that eventually her efforts will inspire similar courses in other health systems.
“Public payers and insurance companies are all making pushes toward value-based models, but the education of physicians on value-based care has lagged behind,” she says. “Our hope is that we can meet the moment with this training to better serve our patients and our community.”
