Price­less pas­sion

$250,000 bill? Physi­cian wants other docs in­cluded in set­ting costs of care

Modern Healthcare - - The Week In Healthcare - Lola Butcher

Dr. Neel Shah was in med­i­cal school when he first no­ticed that the na­tional hand-wring­ing over the cost of med­i­cal care did not in­clude cer­tain hands. Most dis­cus­sion cen­ters on what pol­i­cy­mak­ers should do about health­care costs and some fo­cuses on what pay­ers can do.

“There’s even some dis­cus­sion about what pa­tients should do to be­come bet­ter con­sumers of health­care,” he says. “But there’s al­most noth­ing about what the role of physi­cians should be. That just struck me as crazy be­cause we’re the ones who de­cide what goes on the bill.”

Study­ing at Har­vard Univer­sity’s Kennedy School of Gov­ern­ment af­ter med­i­cal school, he gath­ered some like-minded friends to start a not-for-profit or­ga­ni­za­tion called Costs of Care. Their mis­sion is to help physi­cians un­der­stand how their de­ci­sions in­flu­ence the cost of a pa­tient’s care. But it soon be­came clear they had some up­front work to do.

“We re­al­ized that there are a lot of peo­ple out there that just don’t un­der­stand why it is im­por­tant for doc­tors to be cost-aware right at the point of care,” says Shah, an ob­stet­rics/gy­ne­col­ogy res­i­dent at Brigham and Women’s Hos­pi­tal and Mas­sachusetts Gen­eral Hos­pi­tal, both in Bos­ton.

That’s why Costs of Care launched an es­say con­test, in which physi­cians, nurses, other care­givers and pa­tients told sto­ries il­lus­trat­ing how med­i­cal de­ci­sions caused po­ten­tially avoid­able harm to pa­tients fi­nan­cially.

More than 100 es­says were sub­mit­ted, rang­ing from the hi­lar­i­ous (an $11,000 bill for in­di­ges­tion) to the heart­break­ing ($250,000 for a ter­mi­nally ill man who de­clined treat­ment).

“As some­one who is re­ally pas­sion­ate about this and spends a lot of time work­ing on it, I learned a lot—as did the judges,” Shah says. “They all wrote to me af­ter­ward, and Michael Dukakis has called me a few times to tell me how up­set­ting he found some of these sto­ries to be.”

Like Dukakis, the for­mer Demo­cratic gov­er­nor of Mas­sachusetts and U.S. pres­i­den­tial nom­i­nee, the other con­test judges—sur­geon and writer Dr. Atul Gawande; Michael Leav­itt, for­mer HHS sec­re­tary; Dr. Jef­frey Flier, dean of Har­vard Med­i­cal School; and Dr. Tim John­son, med­i­cal re­porter for ABC News— are savvy about the com­plex­i­ties of Amer­ica’s health­care sys­tem. The fact that the per­sonal anec­dotes made such an im­pact on them con­vinced Shah of their po­ten­tial to change the way physi­cians prac­tice.

Judges for the next es­say con­test com­ing ex­penses,” Maa says. “I have re­ceived feed­back about the es­say from read­ers in France, Poland and other Euro­pean coun­tries who were stunned to re­al­ize that his type of tragedy oc­curs in Amer­ica.”

He is re­fer­ring to the ex­pe­ri­ence of his 59-year-old un­cle, who was work­ing but unin­sured when he was di­ag­nosed with a ter­mi­nal ill­ness. Want­ing to save money for his daugh­ters’ ed­u­ca­tion, Maa’s un­cle re­fused in­ten­sive-care treat­ment and emer­gency depart­ment vis­its and had a do-notre­sus­ci­tate or­der. He died 72 days af­ter he first be­came ill, but his to­tal med­i­cal bill was still $250,000.

Maa agrees that most physi­cians have lit­tle un­der­stand­ing about the costs of the health­care ser­vices they pro­vide, and they should ed­u­cate them­selves about the con­cept of “value” in health­care de­liv­ery. But he is more con­cerned about the way health­care prices are set.

“In the end, doc­tors play only a min­i­mal role in set­ting the prices and rates of re­im­burse­ment in our de­liv­ery sys­tem,” he says. “Our gov­ern­ment, in­surance plans, hos­pi­tal as­so­ci­a­tions and hos­pi­tal ad­min­is­tra­tors should care­fully eval­u­ate the pro­cesses by which the rates for a hos­pi­tal bed, lab­o­ra­tory work, time in the op­er­at­ing room and other charges are de­ter­mined.”

While Shah and his Costs of Care col­leagues would not dis­agree, they be­lieve that, if given the right in­for­ma­tion, physi­cians will be will­ing to do what they can to hold down a pa­tient’s costs. They are de­vel­op­ing a smart­phone ap­pli­ca­tion—which they in­tend to make avail­able at no cost—that al­lows emer­gency physi­cians to quickly check the rel­a­tive cost of al­ter­na­tive op­tions.

Cur­rently, Shah says, physi­cians have no way of know­ing such ba­sic in­for­ma­tion.

“When I need to or­der an MRI, there’s a list on a com­puter screen, and I click ‘MRI,’ and then I sign it, and I’ve or­dered it. That’s it,” he says. “If you’re or­der­ing from a menu that doesn’t have any prices on it, it’s re­ally easy to get the filet mignon ev­ery sin­gle time.” Lola Butcher is a free­lancer health­care writer in Spring­field, Mo. Con­tact Butcher at lola@lo­

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