• Raising Cost Awareness Among Physicians

    An interview with Neel Shah, MD Mar 01, 2013

    Clinicians who see a menu of treatment options without any prices tend to order the priciest item every time. What’s needed are decision-support tools that help caregivers know when less expensive is the better choice, says one physician.

    Neel Shah

    When Neel Shah, MD, began treating patients in medical school, he started hearing the questions most physicians hear these days: “Why was that bill so high? How much will this procedure cost? How can I possibly pay for this?”

    “It just bothered me that I had to tell my patients that I didn’t know, and it surprised me that, when I asked around, it was so difficult to get the answers for patients,” he says.

    Costs of Care

    He decided to get the answers for himself. After his third year of medical school, he took a break from the hospital to earn a graduate degree in public policy at the John F. Kennedy School of Government, Harvard University. By the time he returned, he had founded a not-for-profit organization called Costs of Care. Its mission: to empower patients and their caregivers to deflate medical bills. 

    “It incorporated a month before my intern year, which is a pretty hard time to be starting something,” he says. “It operated very much like an after-school club. We had paperwork that says we were incorporated as a not-for-profit, but really it was just people getting together to talk about ideas.”

    The Value of a Story

    Those ideas, however, resonated widely. Costs of Care launched an essay contest to collect stories from physicians and patients about the importance of cost-awareness in medicine—and attracted essay judges such as former U.S. presidential candidate Gov. Michael Dukakis, former Health and Human Services Secretary Michael Leavitt, and New Yorker staff writer and surgeon Atul Gawande, MD.

    Now in its third year, the essay contest has grown to what Shah calls “a crowd-sourcing mechanism” that gathers personal stories that illustrate opportunities to improve the value of care. “Sometimes a good story is worth a thousand academic papers in terms of motivating change,” Shah says. “Even the Institute of Medicine has tapped into our essay contest to get case studies for its reports to motivate people to think through some of these issues.”

    Moreover, Shah says, the stories inspire physicians to see that they can improve the value of care, making a big difference in the lives of their patients, when they consider costs in their medical decision making.

    Physicians Weighing Value

    Of course, not all physicians understand why they should care about medical costs or how to start doing so. That is why Costs of Care launched the Teaching Value project, a series of web-based videos and curricula to help medical students learn how to reduce overused or misused tests and procedures. 

    The not-for-profit is also working to launch a mobile app that will help physicians make high-value decisions about diagnostic tests. Shah and his team are drawing on lessons from the quality and safety movement to create algorithms that will help physicians know when, for example, an ultrasound is a higher-value test than an MRI. 

    He expects an app to be available in about a year, and he is encouraged that several initiatives—for example, the Choosing Wisely campaign from the ABIM Foundation and the Institute of Medicine’s Roundtable on Value & Science-Driven Health Care—are priming physicians to want decision support to improve the value of the care they deliver.

    “Just in the last year, there’s a lot more momentum to get doctors thinking this way,” says Shah, who is also chief resident in obstetrics and gynecology at Massachusetts General Hospital and Brigham & Women’s Hospital in Boston. “The profession itself is starting to take ownership of this.”

    Neel Shah, MD, MPP, is executive director, Costs of Care, Boston (neel@costsofcare.org).