Resolve to be a rationally prescribing and rationally ordering physician

We’ve all come across a year’s worth of diet and exercise articles online, and it’s only January 2nd. Resolutions are good, resolutions are bad, resolutions can cure hepatitis, our social media feeds are busting at the seams. So I’ll spare you yet another lifestyle-related post. You’re welcome. But seriously, find a combination of exercise and nutrition that you enjoy and do an accurate daily food diary. I’ll leave it at that.

Let me use this demarcation in the Gregorian calendar to speak to those of you who play a role in decision-making in our health care system. Not only physicians and nurse practitioners who order the therapeutics and tests, but also the other allied health professionals who advocate for certain tests.

Let’s all be rational this year. Now I know for some of you irrationality is part of your life blood, but I think we can all afford to be a bit more rational when it comes to what we order.

Looking back at training in medical school and residency, cost is almost never discussed. I don’t think it is omitted out of any malice, but I think the main reason it isn’t discussed is that most staff physicians themselves have no idea what dollar amount to put on therapeutics and tests. I’m sure a handful of them truly don’t care, but I think in our health care system that is over-burdened, we all share a duty to make cost-effective decisions in our practices. Most physicians would rather make a fiscally prudent decision if it resulted in equivalent patient outcomes.

So let’s start with therapeutics. Can you honestly say you know the cost of every prescription you wrote this week? If you can’t, you’re far from alone, as most physicians don’t have a clue. But I think we all realize how absurd this is. Big decisions with big money involved, and ignorance is frankly not justifiable. Patients and the public expect that our therapeutic decisions are evidence-based and cost-effective.

“But the medications are covered under their plan”. The health care economy (including private insurance coverage) is a zero-sum game. That wasted money is coming out of somewhere else. So please never use that excuse. It’s lazy.

I often hear from physicians that finding out these exact costs is difficult, Which in some cases is very true, as the prices are not easily searchable online. But rather than simply resign yourself to not knowing the exact price, take a bit of time to educate yourself on the approximate costs. Here is a fantastic resource from the Alberta College of Family Physicians with the costs of commonly-prescribed medications. Take 5 minutes and read this document. You will be surprised by the costs within many of the medication classes. Ezetrol is 4-5 times more expensive than a generic statin. Adalat is almost double the cost of amlodipine. Coversyl is 5 times more expensive than generic ramipril. Brillinta (ticagrelor) is 4 times more expensive than Plavix. Glumetza is 8 times more expensive than generic metformin. Zyban is 4 times more expensive than using wellbutrin SR. Brand Nexium dwarfs the cost of other proton pump inhibitors. Look at the costs of Cipralex, Pristiq and Cymbalta. Check out Avodart vs. Proscar. (Bear in mind that these are prices from Alberta, but the general trends will hold from province to province). The Ontario Drug Benefit Formulary is also useful for comparing prices of medications.

Now you may have a justifiable clinical indication for using the more expensive option, which is why they are included in the formularies to begin with. But you need to know the magnitude of the cost differential before you make that decision.

What about ordering tests? I won’t spend any time discussing imaging, because that seems to be one area where physicians are already slowly becoming more rational. We know imaging is expensive, and we generally always think twice before ordering it.

So I’ll focus my energies on lab testing. As a medical student, I remember working with a surly emergency physician who was borderline militant with forcing me to justify every blood test I wanted to order. While my less mature self was frustrated with this tedious process, I have come to appreciate this approach. He’s still a jerk, but he’s a rationally ordering jerk.

The checklist forms provided here in the community in Ontario lend themselves quite easily to over-testing. Want a test? Just check a box. You don’t even have to consciously think about the clinical problem, just peruse the form for your selections. The form has been revised for the better in recent years, with the TSH, B12, ferritin and AST removed from the checkbox area. But it’s still too easy, so you have to actively think about whether the tests you are ordering are imperative.

Finding the costs of OHIP-covered tests in the community is actually quite challenging. None of the community labs I contacted would agree to provide me a complete list of the reimbursement prices for lab tests. They would however give me the price of specific tests I asked for, so I was able to make some rough estimates. To determine an approximate cost, visit the OHIP Schedule of Benefits for Laboratory Testing. Take the “LMS Units” on the right side of each test, and the cost in dollars is roughly 35-50% of that number. Ferritin is 28 LMS Units, and costs $10.34. CBC is 16 LMS Units and costs $6.72. On top of the costs of individual tests, the lab will then charge OHIP an additional $7.76 for a “Patient Documentation and Specimen Collection Fee”. Take 5 minutes to peruse the list and you’ll find at least a few surprises.

(Here is a list of non-OHIP covered tests. The price lists are available to providers upon request to the lab, but I am not allowed to post it publicly. It is a useful resource to have in the office.)

The dollar amounts for tests ordered in hospital doesn’t follow this formula, as the testing typically comes out of a global budget . But the theory still stands, that fewer tests ordered results in cost savings and more money for other valuable patient care. Again you may have a justifiable clinical indication for that expensive test, so do what you think is in your patient’s best interests. But know the approximate cost of that decision.

Why did you just order that chloride level in a stable outpatient? Why have you ordered their magnesium level as an inpatient every day for the past week? It was normal on days 1-6, I think you were ok to skip day 7. Ordering a patient’s lipids to check compliance? Ordering serial vitamin D levels in a patient with uncomplicated osteoporosis? (The elephant in the room here are “naturopathic MDs” who are burdening the system with piles of unnecessary tests covered under OHIP, but for now we can only control our own behaviours and order with our own conscience.)

(Hat tip to Dr. Zain Chagla, Infectious Diseases expert, in the comments section for mentioning the likely direct patient harms with over-testing. We’ve all seen that incidental elevated lab value lead down a rabbit hole of further testing, costing the system boatloads of money and the patient a lifetime’s worth of anxiety, all to discover there was no pathology.)

To implement rational decision-making in primary care is fairly simple. Our days consist of a marathon of small decisions where cost-savings can be found. If you look for them, you’ll find them. Finding these same opportunities in sub-specialty care can be a bit more tricky, but still possible. Spend the next two weeks asking mentors and colleagues what your commonly-used therapeutics and tests cost. If they don’t know, try and find the answer. Are there safe lower-cost alternatives?

So let’s spend 2015 being rational. And try to stay rational for longer than you stick to your other resolutions.


2 thoughts on “Resolve to be a rationally prescribing and rationally ordering physician

  1. Zain chagla

    Great post Mario
    I think the one thing to add would be potential harms of excess testing, not just costs

    As an intern the referrals for a slightly high ferretin or an elevated alk phos were just disasters…costing the system more money, and the patients have no clue why it was ordered

    Now I see tons of folks with inappropriately ordered and treated utis often with multidtug resistance or c difficile as a consequence of they’re irrational clinicians. They are often shocked when I say I don’t need to treat you when I find bacteria in your urine without symptoms.

    One question to you is do you think rationality will change for the positive or negative when patients have easy online access to lab results? This is already happening in the states


  2. Kate

    Another great post, Mario. Thanks for the links! I was actually contemplating working a shift as a PGY-5 with the rationally ordering jerk who shall remain nameless to go through that process again with him. Maybe I will.



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