Q&A with Dr. Neel Shah, Part 1: Getting Doctors to Consider the Costs of Care
When it comes to talking about America's rising health care costs, many fingers have been pointed at pharmaceutical companies, malpractice lawyers, health insurers and patients themselves. Dr. Neel Shah wants another group to start thinking about its own role in driving up health costs - rank and file doctors. Physicians simply aren't trained to think about how the treatment decisions they make affect what patients are going to pay.
They should, Shah argues. A Harvard-affiliated resident at Brigham & Women's Hospital, Shah started Costs of Care to spread this message and develop tools to help doctors consider costs when prescribing treatments. The nonprofit organization has launched an essay contest offering a $1,000 prize for the best story, from doctor or patient, on how doctors' decisions affect patients' finances. Finalists have been selected (Atul Gawande is one of the judges) and the winners will be announced Dec. 15.
Recently, Shah talked with me about his work and how journalists might improve their coverage of health care costs. The first part of our conversation, below, has been edited for length and clarity. Next week, I'll share some ideas from Dr. Shah on how journalists can better cover the national discussion on health care costs.
Q: How did you come to create Cost of Care?
A: I started the organization as a medical student. What we're trying to do is deflate medical bills. Everybody knows that health care costs a lot - but we were seeing patients who were getting these large, unexpected bills. Doctors don't know how the decisions they're making are going to affect what patients are going to pay. Health care prices are very opaque. We're just not trained to think about costs. We thought we could try to reframe cost debate between doctor and patient.
Q: How do you answer people who might view Costs of Care as promoting rationing of health care, or reducing people's access to health care?
A: When you talk about cost control, people always think about quality. A lot of our work has been to reframe the debate. We don't want people to not get tests. We don't want them to get tests that don't help them and don't raise their medical costs unnecessarily. Doctors should know what things cost.
Q: Wouldn't doctors see admonitions to pay attention to treatment costs as undermining their authority? There were a lot of battles over this issue when managed care was on the rise.
A: Managed care was (promoting) a top-down approach, telling doctors what to do. This whole time that costs have been skyrocketing, the world has changed in that we have much more access to information. Now we can have a transparency that wasn't there during the managed care debate.
There's a lot of discussion about what patients and insurers should be doing to lower health costs. Throughout the health care reform debate, there was no discussion about what doctors should do. People were very reluctant to discuss doctors' role.
Doctors aren't setting the prices, but a lot of services doctors provide aren't providing a lot of value at the bedside. Doctors use two criteria to make decisions: making sure that (a treatment) is safe and has reasonable chance of working. In the future, they might consider (whether the treatment) is cost-effective, too.
Q: How do you plan to help doctors address costs at the bedside?
A: The way we've been explaining our approach is to use information technology to tell doctors what something costs. Healthcare lags behind other industries in information technology adoption – there are a lot of barriers (including) patient privacy. We need to get around the operational barriers.
We're creating an iPhone app - it's very easy to give that out. We're going to give doctors a menu, such as the cost of tests in an ER setting. It'll be organized by chief complaint like chest pain. We'll highlight low-value services.
Q: Can you give an example of how giving doctors this information might help patients save money?
A: One example is diagnostic imaging in the emergency room, where a lot of people tend to get high bills and where people with low or no insurance get their care. If I'm the resident and there's a patient, I can order three tests to figure out what's going on. If I don't have a lot of time and I'm supposed to get that person out of my ER, I'll order six tests. It's just our culture of ordering.
Q: Is there consensus on the utility of various tests?
A. Well, no. Protocols can provide protection for doctors for not ordering the test. We measure adherence to protocol. Because it's really difficult (to reach consensus), we think the first step should be helping people to know what things cost. The next step will be how to integrate costs into decision-making.
Q: Who funds your work?
A: Small grants from the Katherine B. Reynolds Foundation, Harvard Pilgrim Health Care, Blue-Cross/Blue Shield of Massachusetts, and a bunch of small donations.
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Q&A with Dr. Neel Shah, Part 2: Ideas for covering the cost of health care