The app, called ProvenExperience, has only just launched, and it will be interesting to see whether it gives patients more agency and, in so doing, perhaps obviate the need for some lawsuits. Will other providers feel pressure to connect costs to results, and give patients a way to express feedback, in a similarly concrete way?
Meanwhile, some people, such as Neel Shah, are dealing more directly with the costs of services, as opposed to just their value. Shah, 33, is an assistant professor at Harvard Medical School, an OB/GYN, and the founder of a nonprofit that collects first-person accounts from patients and doctors about health-care costs. His goal, as well as the nonprofit’s, is to save patients money without adversely affecting their health outcomes.
Patients, providers, and insurers alike have a role to play. That includes doctors, he acknowledges: According to his nonprofit, Costs of Care, clinicians’ decisions dictate how about 90 percent of health-care dollars are spent.
I spoke to Shah one evening after he got off work, and he told me that there’d been a lot of births that day. I asked him how many C-sections he performed. “I did a lot, to be honest,” he said. “I like to think they were necessary.”
If he sounded a bit rueful, it was because C-sections are one of the most enduring, expensive mysteries of modern health care. They command about a 50 percent margin over a vaginal delivery and can cost a patient about $10,000 more, though the exact amount varies state by state. Because C-sections are surgeries, they can result in much more serious complications. Yet, Shah told me, they have gone up in frequency about 500 percent in the past several decades, and no one can accurately, satisfactorily explain why. (In 1970, one in 20 American babies was born via Caesarian; nowadays the rate is one in three.) “Generally speaking,” said Shah, “about half could be avoided in retrospect—‘in retrospect’ being the key words there.”
The fact that Shah is not afraid to implicate himself, let alone his sub-specialty, in his discussions of what should change may be part of the reason he has succeeded in making some headway on the issues he cares about. A new Costs of Care textbook titled Understanding Value-Based Healthcare, for example, helps students conceive of medical care in terms of what works and what’s wasteful. And the organization has been able to partner with much larger and more well-established players such as the American Board of Internal Medicine Foundation to brainstorm, and eventually implement, real changes in how medicine is practiced in the U.S., with the goal of bringing costs down.
When Shah was in medical school in the late aughts, he noticed that no one was discussing the financial aspect of practicing medicine. As a third-year, he said, “everyone above you, even the 4th years, seems omniscient, but the one thing no one had any insight into was how our decisions were impacting what anybody paid.”