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Aim Cost awareness has been proposed as a strategy for curbing the continued rise of healthcare costs. However, most physicians are unaware of the cost of diagnostic tests, and interventions have had mixed results. We sought to assess resident physician cost awareness following sustained visual display of costs into electronic health record (EHR) order entry screens. Study Design We completed a preintervention and postintervention web-based survey. Participants were physicians in internal medicine, paediatrics, combined medicine and paediatrics, obstetrics and gynaecology, emergency medicine, and orthopaedic surgery at one tertiary co are academic medical centre. Costs were displayed in the EHR for 1032 unique laboratory orders. We measured attitudes towards costs and estimates of Medicare reimbursement rates for 11 common laboratory and imaging tests. Results We received 209 survey responses during the preintervention period (response rate 71.1%) and 194 responses during the postintervention period (response rate 66.0%). The proportion of residents that agreed/strongly agreed that they knew the costs of tests they ordered increased after the cost display (8.6% vs 38.2%; p Conclusions Resident cost awareness and ability to accurately estimate laboratory order costs improved significantly after implementation of a comprehensive EHR cost display for all laboratory orders. The improvement in cost estimation accuracy for imaging orders, which did not have costs displayed, suggested a possible spillover effect generated by providing a cost context for residents.

In the USA, the politics around healthcare reform have created polarised views of the Affordable Care Act (ACA), but underlying these views is a disquieting lack of knowledge that could have harmful consequences for patients. Recently, television host Jimmy Kimmel interviewed a series of citizens on the street, all of whom vehemently stated their objections to Obamacare but were supportive of the ACA, suggesting misperceptions and lack of knowledge about the legislation among the public. But this is not just a case of late-night comedy. A recent Commonwealth Fund Health Insurance Marketplace Survey found that only two out of five adults in the USA were aware of health insurance exchanges or that there might be financial assistance to purchase plans.1 Even among childhood cancer survivors with substantial long-term healthcare needs, almost all participants surveyed did not have knowledge about health-insurance related laws.2 Physicians, who are experts in practicing medicine, are often assumed by patients to be experts in the legal changes affecting healthcare delivery. However, the reality is that most physicians are not experts in health policy,3 and it is not only the public that lacks knowledge about the ACA. In a recent survey of 2958 physicians in the USA, 45% did not know what an accountable care organisation was, but 65% felt that healthcare will deteriorate over the next 5 years after passage of the ACA, while only 27% believed the ACA will have a positive effect on patients.4 Furthermore, despite the ACA increasing Medicare and Medicaid reimbursement to …

Whether in the USA or UK, the resounding question in the health sphere is: How do we achieve better value in healthcare? The answer to date has been simple: get bigger, merge administrative departments, get more managerialised, and so cut costs. But none of this represents real change: just some tinkering of the current hospital-centric system. In order to find a sustainable and effective solution, we must consider value and not cost while focusing on what contributes to better health. This means becoming serious about caring for people beyond a hospital's walls. Population health, which links health outcomes for a population to the context of medical system and social determinants of health,1 offers the promise of dramatic improvement in value and personalisation for patients. This is not to diminish or downgrade the importance of continuing to improve healthcare for the individual, but rather to link that with an active approach to improving health. Doctors and other healthcare professionals will need to refocus their roles and renegotiate their relationships across the healthcare sector. Health systems across the globe are pressured to derive greater value in healthcare, which in the context of the continuing groundbreaking developments in medical technology must now centre on becoming serious about population health. The Institute for Healthcare Improvement's triple aim sets out the laudable ambition for all health systems: improving the health of populations, enhancing the patient experience of care, and reducing the per capita cost of healthcare to ensure benefits can be applied across communities. It is the first of these, improving the health of the population, that is the most difficult and which seems out of the scope of healthcare. Delivering on this promise will not happen without clear leadership. Primary care—which assumes nearly 60% of all US patient visits and 90% of …