After writing recently about a contest sponsored by the non-profit Costs of Care, I became intrigued by the aim of the Boston-based organization and its founder and director, Neel Shah, MD. How, I wondered, were Shah and his colleagues going to reach their goal of educating physicians on how the decisions they make impact what patients pay for care? And would physicians be receptive? I posed these and several other questions to Shah, who is currently a resident at Brigham & Women's Hospital; our conversation is below.
Your organization's website notes that you learned as a medical student that “even the best doctors sometimes neglect something critical - the bill.” How did you come to realize this?
As a student, I heard murmurs in the hospital wards about certain services being expensive or potentially uncovered. But I never imagined how expensive routine care can be or how common it is for even insured patients to be exposed to unexpected costs. The first time a patient asked me how much all the lab tests we were ordering would cost I told her I didn't know but would find out. The problem was that no one around me knew either, not the residents, and not the attendings. She was among the many Americans who have high deductible insurance plans and have to pay the first $2,000 dollars of health expenses out of pocket. As it turns out, many lab tests cost hundreds of dollars and don't always give us useful information.
I realized that at the end of the day, clinicians like me decide which tests and treatments go on the bill. Nonetheless, we rarely understand how our decisions impact what patients pay. I recognized that there might be an opportunity to save money for individual patients and for the system as a whole just by empowering medical decision-makers with cost information at a grassroots level.
How did you come to start Costs of Care? And how is it different than other organizations that strive to address the health-care cost issue?
There are many very smart people working on the cost containment problem, but the majority of this effort is focused on the role of policymakers, payers, and even patients. When we started Costs of Care we decided that we would differentiate our work by focusing on the role of doctors, nurses, and other care providers. Compared to every other stakeholder in the health care system, clinicians are likely to be the best positioned to recognize inefficiency and then act on it.
Of course for many clinicians, cost-consideration is a radical idea. There is a long held ethos in our profession that compels us to do everything possible for our patients, and cost-consideration can seem at odds with this. The challenge has always been that conversations about costs are abstracted to the population level. Doctors are trained to take care of the patient in front of them, not to assume responsibility for the percentage of GDP the United States spends on health care.
With this insight, Costs of Care has found success by delineating scenarios where cost-awareness can have positive impact on individual patients while also paying particular attention to the pragmatic and ethical barriers to cost-consideration that clinicians face when they are at the bedside.
One of your organization's goals is to use information technology to show providers prices at the critical moment when medical decisions are made. Can you describe how you do this?
Among the pragmatic challenges to cost consideration is that cost information is rarely available at the point of decision. However, the whole point of information technology is to put information where it is supposed to be, when it is supposed to be there. To that end we advocate for inclusion of explicit cost information in physician order-entry systems and are developing a mobile application that will allow doctors to easily look up the costs of tests in treatments in the same way they look up dosages of medications. We also recently received a grant from the American Board of Internal Medicine Foundation to develop web-based CME modules aimed at educating physicians about how to actually use this cost information - where it fits within their workflow and how it can make a difference in the care they deliver.
How do you respond to those who may argue that doctors should only consider what’s best for the patient – not the costs of treatments – when delivering care?
Currently, two conditions have to be met before making a medical decision. The first is to do no harm. You have to make sure that what you want to do is safe. The second is to make sure that what you want to do has a reasonable chance of helping. For most decisions today, if it is safe and it works, we go ahead and do it. However in the near future resource constraints will compel us to not only make sure our decisions are safe and potentially helpful, but also cost-effective. While it would be nice if physicians didn't have to assume responsibility for this, somebody has to and I'm concerned that having third parties make cost decisions would be much worse.
You’re currently a resident. How has your work and views on costs affected the way you treat patients and approach tests and treatments?
I try to be thoughtful about the cost implications of the tests and treatments I order but realize there are many strong incentives to over-order tests, especially as a resident, and I am often as guilty as anyone else. My own experiences with patient care have made me realize that empowering clinicians with cost information is only the first step. We also have to provide an infrastructure that allows physicians to act on this information, with specific and institution wide resource allocation guidelines, and peer support for resource stewardship.