“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 up this fall include former White House Budget Director Peter Orzag and former Surgeon General C. Everett Koop. The essays are being published at costsofcare.blogspot.com and thehealthcareblog.com.
One of them was written by Dr. John Maa, director of the surgical hospitalist program at the UCSF Medical Center, San Francisco.
“Fundamentally, the real tragedy in America is the number of people who become bankrupt due to medical 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-not-resuscitate 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 [email protected]