Freelisting on Costs and Value in Health Care by Pediatric Attending Physicians

Published:April 09, 2015DOI:



      In preparation for the development of a curriculum on health care costs and value for pediatricians, the goal of this study was to assess pediatricians' baseline perceptions about the concepts of “cost” and “value” in health care, and topics that should be included in a curriculum that teaches about costs and value in pediatrics.


      Physicians in the Department of Pediatrics at The Children's Hospital of Philadelphia received an online freelisting survey asking them to generate lists of words that come to mind when thinking about “costs” in health care, “value” in health care, and topics to include in a curriculum on costs and value in pediatrics. AnthroPac software generated salience scores, indicating the relative importance of each term.


      A total of 207 surveys were completed for a 40% response rate. For the “cost” prompt, the most salient responses were “excessive,” “waste,” and “insurance.” For the “value” prompt, the most salient responses were “outcomes” and “quality.” For elements to include in a curriculum, the most salient responses were “insurance” and “costs.” Analyzing responses based on years in practice, percentage clinical time, and division resulted in slightly different lists and salience scores.


      In this freelisting exercise, there was general agreement that health care costs are “excessive,” that “outcomes” and “quality” are integral to value, and that there is a need for education in these areas, especially around “insurance.” Differences based on years in practice, percentage clinical time, or division can inform the development of targeted curricula that consider the needs, knowledge, and interests of these groups.


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        • Porter M.E.
        • Lee T.H.
        The strategy that will fix health care.
        Harvard Business Review. 2013; (Available at:) (Accessed August 22, 2014)
      1. Brennan N, Cafarella N, Kocot SL, et al. Improving quality and value in the US health care system. Brookings Bipartisan Policy Center. Available at: Accessed August 22, 2014.

        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
      2. Robert Wood Johnson Foundation; Network for Regional Healthcare Improvement. From volume to value: transforming health care payment and delivery systems to improve quality and reduce costs. Available at: Accessed August 22, 2014.

      3. World Bank. Health expenditure, total (% of GDP). Available at: Accessed August 22, 2014.

      4. US Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. September 6, 2012. Available at: Accessed August 22, 2014.

        • Fieldston E.S.
        Pediatrics and the dollar sign: charges, costs, and striving towards value.
        Acad Pediatr. 2012; 12: 365-366
        • Gower T.
        Should doctors consider medical costs?.
        Boston Globe. 2014; (Available at:) (Accessed August 22, 2014)
        • Cooke M.
        Cost consciousness in patient care—what is medical education's responsibility?.
        N Engl J Med. 2010; 362: 1253-1255
        • Sachdeva R.
        The need for physician education in health care costs to enhance efficiencies in care delivery.
        Pediatrics. 2013; 131: 1184-1185
        • Graham J.D.
        • Potyk D.
        • Raimi E.
        Hospitalists' awareness of patient charges associated with inpatient care.
        J Hosp Med. 2010; 5: 295-297
        • Rock T.A.
        • Xiao R.
        • Fieldston E.
        General pediatric attending physicians' and residents' knowledge of inpatient hospital finances.
        Pediatrics. 2013; 131: 1072-1080
        • Weinberger S.E.
        Providing high-value, cost-conscious care: a critical seventh general competency for physicians.
        Ann Intern Med. 2011; 155: 386-388
        • Dongre A.
        • Deshmukh P.
        • Kalaiselvan G.
        • Upadhyaya S.
        Application of qualitative methods in health research: an overview.
        Online J Health Allied Sci. 2009; 8
        • Weller S.
        Cultural consensus theory: applications and frequently asked questions.
        Field Methods. 2007; 19: 339-368
        • Borgatti S.P.
        Elicitation techniques for cultural domain analysis.
        in: Schensul J.J. LeCompte M.D. Nastasi B.K. Borgatti S.P. Enhanced Ethnographic Methods. AltaMira Press, Walnut Creek, Calif1999: 115-150
        • Borgatti S.P.
        Cultural consensus theory.
        in: Schensul J. Weeks M. The Ethnographic Toolkit. Sage Publications, Newbury, Calif1999
        • Smith J.J.
        • Borgatti S.P.
        Salience counts—and so does accuracy: correcting and updating a measure for freelist item salience.
        J Linguistic Anthropol. 1998; 7: 208-209
        • Kern D.E.
        • Thomas P.A.
        • Hughes M.T.
        Curriculum Development for Medical Education—A Six-Step Approach.
        2nd ed. Johns Hopkins University Press, Baltimore, Md2009
      5. US Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Available at:∼/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed December 29, 2014.

        • Sachdeva R.C.
        • Jain S.
        Making the case to improve quality and reduce costs in pediatric health care.
        Pediatr Clin North Am. 2009; 56: 731-743