The relationship between cost efficiencies and quality of care cannot be overstated. Previous research shows that improved knowledge of some basic costs that are under the control of the provider can help in overall cost control, while maintaining high-quality care. Medical decisions should never be made based only on the cost associated with them. However, when there is more than one way to effectively treat a patient, the more cost efficient choice should be chosen. A good example is the use of intravenous (IV) medication vs oral medication. There are times when either the medication only comes in an IV form or when the IV form is more effective in terms of time to onset or bioavailability. When any difference in time to onset and bioavailability does not affect the patient’s care, this would be a good opportunity to choose a lower-cost oral alternative.

Previous studies show that overall expenditures tend to decrease when physicians are informed on costs (eg, common lab tests). Other research utilizing this strategy indicates that high-quality care can be maintained while reducing costs.

For a study published in the Journal of the American Osteopathic Association, Kevin Hoffman, DO, and Michelino Mancini, DO, researched emergency department providers’ understanding of the costs of care for three routine patient presentations. “Our study used clinical vignettes and cost determination for the entire visit,” says Dr. Hoffman. “This is in contrast to previous research, which has focused on cost assessment of individual tests or medications. We wanted to use a study design that was more realistic and applicable to the way we work in the ED. The hope is that with this research based on clinical scenarios that the data will be more easily translated back into real-world improvements to efficiency in the ED.”

The data show that ED providers continue to have poor understanding of the costs of routine ED care, explains Dr. Hoffman. For the three cases presented (Table 1, Table 2, Table 3), correct answers were chosen by only 43%, 32%, and about 40% of participants, respectively. Cost determination was not related to geographic region, whereas larger institution size was related to greater cost chosen.

“Of particular interest was the relationship we observed between level of training and perceived level of understanding costs,” says Dr. Hoffman. “A trend emerged in which those with higher levels of training (attending physicians with more experience) thought they understood costs well; however, their rates of accurate answers were no greater than those of the other participants. While our research was not tailored to look for this relationship, it was the most statistically significant correlation found. We believe this correlation shows that cost education is not something that you can just pick up on the job or become knowledgeable about over a career. It is something that a provider likely needs to be intentionally taught.”

In medicine there are four main tenants of care: beneficence, non-maleficence, justice, and autonomy. “The lack of knowledge around cost of care can threaten the justice tenant when physicians are not able to be good stewards of limited resources,” says Dr. Hoffman. “This, in turn, can potentially limit equality among patients. In order to develop rational approaches to improved efficiency, clinicians first need to understand the costs of care.”


Hoffman A, Mancini M. Emergency health care professionals’ understanding of the costs of care in the emergency department. J Am Osteopath Assoc. 2017;117:359-364. Available at


Irvin C, Fox J, Pothoven K. Financial impact on emergency physicians for nonreimbursed care for the uninsured. Ann Emerg Med. 2003;42:571-576.


Allan G, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007;4:e283.


Broadwater-Hollifield C, Gren L, Porucznik C, Youngquist S, Sundwall D, Madsen T. Emergency physician knowledge of reimbursement rates associated with emergency medical care. Am J Emerg Med. 2014;32:498-506.