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Foreword – Stev..
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Steven E. Weinberger, MD, FACP

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Executive Vice President and Chief Executive Officer, American College of Physicians

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It is difficult to find an issue that simultaneously has as much financial impact on individuals, families, corporate America, and both state and federal governments as the cost of healthcare. As President Obama concisely made the case to attendees at the 2009 annual meeting of the American Medical Association: “Make no mistake: The cost of our healthcare is a threat to our economy. It is an escalating burden on our families and businesses. It is a ticking time bomb for the federal budget. And it is unsustainable for the United States of America.” These days in Washington, DC, there is little consensus across the political spectrum about virtually anything—except perhaps the magnitude of the problem of healthcare costs and the urgency with which it must be addressed.

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In general, when we pay more for the same type of product or service, we expect to get something of higher quality or more value. Unfortunately, that principle does not hold when we are talking about healthcare. Despite healthcare expenses approaching $3 trillion and 20% of GDP, our health outcomes are no better—and in many cases worse—than those in industrialized countries that spend far less per capita on healthcare. I will not recount the many factors responsible for the relatively high cost and low value of healthcare in the United States, which are covered so beautifully and comprehensively in this authoritative treatise that links the care that patients receive and the dollars that individuals, organizations, and government spend to get that care.

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A major theme throughout this book is waste—dollars spent that provide no benefit to patients, that is, care that is overused or misused. I can provide my own personal experience as a patient when, several years ago, I had a torn medial meniscus in my knee. After it became clear that my symptoms were not resolving on their own, my orthopedist and I agreed that it made sense for me to have arthroscopic surgery. When setting a date for the surgery, the scheduler told me that I first needed to complete my preoperative testing, which included a chest radiograph, an electrocardiogram, and a battery of blood tests. Fortunately, I am healthy, and there was nothing in my medical history to suggest that any of these tests would be of value to me, to my care, or to the orthopedist who would be performing the arthroscopy. None of these tests is individually enormously expensive, but when we add them up and then multiply by the number of individuals across the country who have unnecessary preoperative testing, we are now talking about “real money.”

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I can also provide my perspective as a physician who speaks frequently about high-value care and the problem of overuse and misuse. When I first gave talks on the topic, focusing on overused diagnostic testing, I was concerned about getting pushback or at least excuses from physicians: concerns about malpractice liability because of a missed diagnosis; patients who expect “high-tech” diagnostic services; a commitment to do everything for patients and not worry about costs, etc. To my surprise, this has not been the reaction. Instead, the overwhelming response from physicians in the audience is to recount their own stories—speaking as physicians who feel that they (and their colleagues) are overusing or misusing care, as patients who have had their own personal experiences, or as family members of individuals who have suffered from overused care or its exorbitant cost.

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The three authors of this book have done a superlative job in covering the critical topics relating to healthcare costs and value. Their comprehensive presentation of data and literature citations is accompanied by many stories that illustrate the problems we are confronting and must address. They have successfully conducted a “root cause analysis” of the problem and, not unexpectedly, have identified and discussed many contributing factors. But most important, they have not just thrown up their hands in frustration, but instead have nicely detailed the solutions and tools that are being applied—and must be expanded and extended—to treat this critical problem. Their practical approach focuses on several important areas: the training environment; the role of patients; cost-effective medication prescribing; appropriate screening; and use of financial incentives (or penalties) to change the behavior of physicians and other healthcare providers.

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Now the ball is in our court. We must take the messages delivered in this book and apply them to the care we deliver to our patients. As individuals and as a nation, we generally strive to become #1. But being #1 in healthcare costs is not a desirable goal. Being #1 in healthcare value—which I like to define as the benefit of care we provide relative to its costs and harms—is the goal to which we should strive. It is the responsibility of each and every one of us who are part of the healthcare system to do our part in achieving this goal. We owe it to ourselves, our patients, our profession, and our society.

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