Q&A with Dr. Neel Shah, Part 2: Ideas for covering the cost of health care
Last week, I posted the first part of my conversation with Dr. Neel Shah, founder and executive director of Costs of Care, a nonprofit that urges doctors to consider how their treatment decisions affect patients' pocketbooks and is developing tools to help them do so. He's also willing to provide journalists with names of doctors who are willing to be interviewed on their role in the health care cost debate (you can contact him via info [at] costsofcare [dot] org.)
Below, Shah shares his thoughts on current news coverage of health care costs and offers some story ideas. Our conversation has been edited for length and clarity.
Q: What do journalists get right in their coverage of health care costs, and what do they get wrong?
A: One thing I see really often is that there always has to be a bad guy. The insurance company is the easiest to blame. Then the health care provider, if large, is easy to blame, too.
It's hard. There's a lot of nuance. We've got a system where you've got a payer, a provider and a patient; all three are culpable in health care costs. Whenever there's a situation when a cost is outrageous, prompting (journalists) to write about it, often the root problem is three different parties with three different sets of information. All three parties have totally different information about what's going on. The key to leveling the playing field will be transparency.
The second issue is that (journalists) are very good at putting faces on these issues - that's the power of journalism to effect change. But I don't think we're drilling down enough to the bedside conversations between doctors and patients. We don't talk about what's happening between the doctor and the patient at the bedside – that's a huge driver of what's going on, of the MRI that we didn't need to get in the first place.
Q: Who else is advocating that doctors consider the costs of the treatment they prescribe? Do you follow any particular bloggers or people on Twitter?
A: There's a family medicine doctor, Stephen Meyers, who is passionate about figuring out what doctors can do to help patients spend less money. He's writing high quality, thoughtful things. There's also the researcher Amitabh Chandra, based at the Kennedy School of Government at Harvard.
Q: What specific issues do you think journalists should be covering?
A: There are some recurring themes:
First, there's a lot of policy discussion about whether it makes sense to attach insurance to the employer. There are people who fell through the cracks, not because they weren't responsible but because they couldn't get insurance without employment. There's a safety net, Medicaid, for people who don't have (financial) resources. But the unemployment safety net and the Medicaid safety net are counteracting each other. This is where the system breaks down in terms of insurance being linked to employment.
Second: hidden out-of-network costs. A cardiovascular surgeon from Arizona was blown away by his patient's $10,000 bill because he had gotten preauthorization for his surgery. What ended up happening was that the anesthesiologist happened to be out of network.
Third: There's a disconnect between when the care happens and when the bill happens. Weeks later, the patient gets the bill.
Fourth: I would love to see more stories where a doctor orders a test for a patient that is unexpectedly expensive - we have found that this sometimes happens with diagnostic imaging tests such as breast MRI.
Q: What about financial incentives for doctors to order tests?
A: It's more nuanced than that. I'm skeptical that financial incentives are a macro problem in what's driving costs up. When you think about diagnostic imaging, it's not the radiologist who orders the test.
We're not targeting the boutique dermatologist but where lots of uncompensated care is occurring – the emergency room. ER docs are paid on salary; they don't have incentive to order more tests. Doctors are worried about getting sued, but there are nine or 10 other reasons why tests are prescribed for a patient who's insured and paying a 10 percent copayment - it's the MRI that's really hurting them with the bill.
There's a cultural issue where having doctors consider costs is almost taboo. We're not drilling down deeply enough to think about why doctors are ordering unnecessary tests.