Dr. Neel Shah, Founder of Costs of Care

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Mark Masselli: This is Conversations on Health Care I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret some compelling information is been coming out in recent
weeks in the increasing cost of health care in the country especially when it comes to
insurance co verage.

Margaret Flinter: After several years of historically low increase in health insurance cost
for consumers the rates for 2017 are out and some insurance consumers are going to
see 25% increas es in premiums for next year, something I think we all including the
President were hoping to avoid.

Mark Masselli: Analyst have pointed to ensure setting rates to during the first few open
enrollments that were based on speculation that there would be mo re participation from
young people. Rates have been readjusted for the next year to reflect the higher
proportion of older sicker participants and the lack of competition in certain market
places. As many large insurers have also pulled out of the exchan ge.

Margaret Flinter: And employer base insurance is demanding more out - of - pocket cost
than ever before for consumers who get coverage through their employers everywhere
consumer seem to be paying more in out - of - pocket cost.

Mark Masselli: Mm - hmm, as we look at the rising cost of care a growing number of
entities are promoting more cost awareness in care delivery.

Margaret Flinter: And that is something that our guest today is very focused on. Dr.
Neel Shah is founder of Costs of Care a global organizat ion that's aimed at promoting
value base care in medical training, how can we deliver high quality care that also
reflects value for the patients as well as the health care industry.

Mark Masselli: Looking forward to this conversation and also looking for ward to Lori
Robertson Managing Editor of FactCheck.org looks at misstatements spoken about
health policy in the public domain. But no matter what the topic you can hear all of our
shows by going to chc radio.com.

Margaret Flinter: And as always if you ha ve comments please email us at
[email protected] or find us on Facebook or Twitter because we love to hear from
you.

Mark Masselli: But first here is our producer Marianne O'Hare with this week's headline
news.

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Marianne O'Hare: I'm Marianne O'Hare with these health care headlines. Come
January Vermont will become the first state in the nation to move to a voluntary all
payer accountable care organization model. Vermont is using a grant from the Centers
For Medicare and Medicaid for the ACO initiative which will require the same payments
for providers treating patients in Medicare, Medicaid as well as commercial entities.
Governor Shumlin ’s earlier efforts to pass the nation's first single payer system fell the
wayside in 2014 when it was determined the plan would be too cost prohibitive.
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Open enrollment getting underway November 1 for the Affordable Ca re Act market
places with much hullabaloo over the estimated 25% increase in some regions of the
coun try. States that expanded Medicaid and had robust competition in the market
places have seen far lower rate increases in some cases. Many people are weighing
their options of going without insurance coverage altogether during this next round of
open enro llment, many say the penalty about 700 dollars for single person doesn’t
create enough incentive to adhere to the insurance mandate.

Meanwhile what are Americans most concern about when it comes to their health care
cost? Its drug cost, according to a Kai ser Family Foundation poll 75% of the poll saw
the rising cost of pharmaceuticals as their greatest cost for concern. According the
Kaiser's October tracking poll majorities of democratic, republican and independent
voters all support making sure high cos t drugs for chronic conditions are affordable for
patients who need them.

Ah the cranberry the little red berry born of the bug rich in vitamin C and loads of energy
oxidants along held to be one nature's best little fighters against the urinary tract
infe ction. The study conducted by the Yale School of Medicine found women in the
nursing home given high dose cranberry supplements for years showed no less
incidents of urinary tract infections and those not given intervention. Lead author Dr.
Manisha Jutha ni - Mehta says it may not be worth the expense of promoting supplements
to protect against UTIs. I'm Marianne O'Hare with these Health Care Headlines.

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Mark Masselli: We're speaking today with Neel Shah Founder and Executive Director of
Costs of Ca re a global NGO that seeks to help delivery systems provide better care at
lower cost. He's the co - author of highly acclaimed understanding value based health
care. Dr. Shah's an Assistant Professor of Obstetrics Gynecology and Reproductive
Biology at Harvard Medical School with a practice at Beth Israel Deaconess Medical
Center . He's an associate professor at the Ariadne Labs for health systems innovation
where he leads a 50 hospital consortium linking administrative manag ement to clinical
performance. He was named as one of Becker's hospital review 40 smartest people in

health care he earned his master's in public policy at the Kennedy School of
Government at Harvard and his MD at Brown University. Dr. Shah welcome to
Co nversations on Health Care.

Dr. Neel Shah: Thanks so much.

Mark Masselli: You learned pretty early in your medical training about the huge
variations in health care pricing and how medical training did very little to prepare future
clinicians for thinkin g about delivery from the value perspective. And you and a couple
of your partners launched Costs of Care in 2009, I'm wondering if you could share with
our listeners more about the goals of the organization and how that mission is evolved.

Dr. Neel Shah : Absolutely, so generally the way medical school works you spend about
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a quarter century in a classroom and then when you're in 25 grade or so when you're a
third year medical student they finally let you put on a white coat and touch real
patients. An d I actually signed up for medical school at a young age at 18, I was at a
program at Brown that's like a Brown for life thing you sort of do four years of college
and then you go right into med school. And my idea of being a doctor was mostly
based on wh at I've seen on TV. And during your third year medical school your job is to
kind of walk into every door of the hospital and learn what happens there. For the first
time I got a sense of our fallibility as well and in particular I notice that, you know, in
Providence, Rhode Island where I was in school they're not the ones with the deep
pockets and I notice that we are making a lot of decisions in a vacuum without really
any sense of how our decisions impacted what patients are paying. And the most
surp rising thing to me was that when you're a third medical student everybody above
you seems omniscient, you know, even the fourth year medical students. And this is
the one thing that even the most esteemed professors didn’t really have a lot of insight
int o.

Margaret Flinter: Well Dr. Shah the notion of value base care I think has finally start to
really gain some traction in this country and certainly give some credit to that maybe to
the policy initiatives in the Affordable Care Act, but you're in OBGYN you practice within
a pioneer ACO. So you've had a pretty firsthand look at some of the real challenges in
getting organizations and practitioners to think more about value base care, what have
been some of the greatest challenges so far in shifting the c ulture?

Dr. Neel Shah: I mean I think often when people talk about health care reform they're
conflating two things there's payment reform and then there's delivery reform. And I
think that Affordable Care Act, accountable care organizations, value based payments
lot of that has to do with sort of top - down incentive to think more about value. You
know, in 1994 you're still getting AOL, CV s sent to you in the mail and that was the state
of internet. Whereas today the internet's very, very different and every other purchasing

decision we make is based on Yelp and Travelocity and other sites that have
transparent quality and pricing informatio n. And I think there's a similar expectation that
we should be able to do the same in health care, at the same time a lot of patients are
facing very high deductable. So I think, you know, where patients are with this in terms
of their expectations aroun d information and transparency is very different. And I think
in many ways that's what's pushing not just payment reform but like delivery reform, and
now it's incumbent on us as clinicians to figure out how we fundamentally reengineer
the way we deliver care.

Mark Masselli: You know, I think there's been a dramatic rise is recent years in the out -
of - pocket expenses for many of those Americans covered under the Affordable Care
Act and you noted in Massachusetts which just had all -- about a decade of univ ersal
coverage health expenders are still a leading cause of personal bankruptcy and
financial difficulty for consumers. And so tell our listeners about the solutions that Cost
of Care is looking at to incentivize players and payers and providers and cons umers
alike.

Dr. Neel Shah: You know, we are seven, eight years ahead of us to the country in
terms of covering everyone in Massachusetts but now we're seven or eight years ahead
in terms of running out of money to pay for it which are much less proud of. And
because we didn’t have especially nationally with the Affordable Care Act it's not like we
had a new pot of money, we just sort of spread it around more and so there's more
people in the system but those people have less good insurance. The average silver
plan has deductable that's 3, 4, 5000 dollars which is real money for most people. You
know, one CT - scan will be a big -- big part of that deductable so in terms of our work
we've organized our efforts into three areas. We started off primarily as an advocacy
organization trying to build well within the profession the clinical professions to consider
cost because not only was I not taught very much about cost when I was a medical
student but I was actually specifically taught that cost weren't some thing I should be
thinking about.

So, what we've done over the years as we've collected now over 500 stories real stories
from patients, clinicians, and health care administrators as well that illustrate the sort of
routine opportunities to make care more affordable for patients. And we've disseminate
them to well positioned stakeholders and in doing that we've tried to bring attention to all
the opportunity there is to improve care around affordability just by making different
decisions, but then the clin icians on the ground really didn’t have the skills or tools or
knowledge that they needed. And then we realize that you can -- you can educate
clinicians they can have the will to consider cost but if you embed them in systems that
set them up for failure you're not doing any good. So we now have an implementation
piece of our work too that's trying to think about how you design the system around the
clinician to help them make better choices.

Margaret Flinter: Well Dr. Shah I want to talk about your b oo k Understand Value Based
Care, Don Berwick the president emeritus at the institute for health care improvement
who we all know for his contributions to patient safety call this book an instinct classic
because it offered frontline clinicians a raft of prac tical ideas to make health care
dramatically safer. So let's talk about those actionable strategies for individual clinicians
or organizations.

Dr. Neel Shah: You know, the book start off by trying to help people understand why
we are where we are now including why health price is so big. The s econd problem is
that the prices are arbitrarily determined and often inflated, clinicians don’t feel
ownership over that issue because they don’t set prices. The third problem which is the
much bigger problem, you know, about a third of the things that we decide to order as
clinicians don’t measurably improve health care outcomes but we found in our research
in our work that there's actually 10 to 20 other distinct reasons why clinicians do this
which, you know, is much lower hanging fruit than say toward reform and then we get
down to really concrete strategies like how do to high value prescribing all the way to
how to actually design value improvement projects within your delivery system.

Mark Masselli: We're speaking today with Dr. Neel Shah Founder and Executive
Director of Costs of Care and also co - author of Understanding Value Based Health
Care. Dr. Shah is professor at the Ariadne Labs for health systems innovation. And Dr.
Shah you give a great ex ample of how health care has gone far off track and that's the
dramatic rise in C - sections perfor med in this country. We've had Leah Binder from
LeapFrog Group on the show discussing the transparency campaign regarding hospital
C - sections. Tell us the ki nd of strategies you've deployed in your own practice that
might be an example for others.

Dr. Neel Shah: Over the last 20 years the patient safety movement has focus so much
on the problem of too little that in many cases we've overcorrected and C - sectio ns is I
think the perfect example where it's become 500% more common. And what Leah
Binder and others have found actually is that one of your biggest risk factors for getting
a C - section isn't your own risks or preferences but it's literally which door yo u walk like
wh ich hospital you go to. Especially thinking about realizing that it's something about
the hospital that's driving this has been really key. With C - sections, you know, a normal
delivery first time it can usually take 20 hours from when you g o into labor to when the
baby get delivered whereas a C - section takes me 30 minutes I just did one. And, you
know, so there's always a sort of implicit incentive to expedite the process. Emergency
medicine physicians face the same sort of thing where they 've got a complex patient
who comes into the ED, they can either admit which is the low resistance pathway or
they can coordinate care and send them back out into the wild. And the strength of the
incentive to take the low resistance pathway depends on a lot of factors in the clinical
environment including how the hospital is managed.

Margaret Flinter: Another big opportunity I guess is at the level of the practice to make
the decisions about ordering test and prescribing medications and we've followed wi th
such interest the Choosing Wisely campaign which was launched a couple of years ago
now by the American Board of Internal Medicine Foundation. And their goal is to get
providers to think very carefully about the evidence and the need for ordering a tes t
versus the habit and also the over prescription of drugs. Talk about how programs like
Choosing Wisely tie into your view of how we can make a difference in scaling back on
things which are necessary and effecting the cost of care that way?

Dr. Neel Sh ah: Absolutely Choosing Wisely is been tremendous it's become an
international movement in the US, I think there's more than 80 specialties now that all
have the list of the five things within their clinical purview that we do routinely but maybe
don’t ha ve to. You know, including like radiologist and cardiologist and oncologist other
folks who use a lot of expensive health care resources or saying, you know, these are
five things that we do that we don’t need to routinely. And then the other thing what
they do is they take the existing evidence for what we should do and they reframe it.
The challenge though is that there are many things in medicine for which we have
excellent evidence but it doesn’t really change practice. And I think that's sort of wh ere
we are with Choosing Wisely now we've sort of gotten to a point where we've raised
great awareness of these issues but then there is that second step of closing the gap
between what we know we should and what we actually do and one of the best
examples of this gap I think is hand washing.

You know, as an obstetrician a 150 years figured out that if you wash your hands you
cut mortality in half. As we've learned during the Ebola outbreak people are still working
on hand washing although we're still i m perfect at hand washing, we've improved a lot
and we've improved relatively recently by thinking about the barriers to hand washing.
The fact that, you know, there is a day actually when I was a medical student where you
walk in and suddenly hand sanitize r b ecame a thing and washing your hand like from a
couple minute operation to being less than a minute. We start institute 360 degree
feedback so if you don’t use the [inaudible 15:16 ] before walking into the patient room
the nurse or the patient probably will call you out on it. So if you are the one spreading
MRSA from room to room it would get really awkward for you very quickly, and then,
you know, lo and behold hand washing are better. It occurred to me when I was a
resident, academic medical center s are rampantly over utilizing care, the most
expensive places to get care in the country. Yeah the residents are not really motivated
by fee for service so basically endangered servants and they're not motivated by
medical malpractice because they're rel atively protected there's layers of hierarchy
between them and the lawsuit yet they still over order. Often it has to do with other
things that can similarly be systematically solve for has to do with trying to preempt your

future work. So, you know, if you can order five test and not think about it again and
occupy a stretcher that's less good. And so that's just a very different kind of solution.

Mark Masselli: Dr. Shah you -- you're also associate professor at the Ariadne Labs
based on Boston and it' s a Harvard based research lab linking hospitals around the
world to best practices that can improve child birth and maternity experience. Could
you talk about the research you're doing there and who you're partnering with around
the world and what you're learning from this consortium?

Dr. Neel Shah: So Ariadne Labs is a institute it was founding by Atul Gawande, it came
out of the work so they did with the surgical safety checklist which, you know, the same
way that a pilot has to run a checklist before hitting the throttle. Now surgeons have to
do the same before picking up the scalpel, and this intervention reduces mortality in half
from all surgeries on every content basically, so it was a ---

Margaret Flinter: Amazing isn't it?

Dr. Neel Shah: Abso lutely -- after the smallpox vaccine I think the WHO thinks it like
most impactful thing that we did. So there are some thinking about what else and what
are the lessons especially around not even creating the checklist but getting to this
implementation problem we're just talking about how do you -- how you actually get
people to follow it. So this institute rub around this idea that, you know, quality
improvement traditionally is very local and there's this sense that quality improvement
projects don’t scale. In fact if you're trying to do a quality improvement research project
often you don’t even need IRB approval because it's assumed that it has no applicability
outside your hospital but the surgical safety checklist sort of prove to that and many
ot her things medical reconciliation, you know, a lot of these things were truly scalable
on ways that make people better. So this is basically a shop that's run by a surgeon so
it's not a diagnosis shop it's an intervention shop where the idea is to do this in a variety
of health care domains and as an obstetrician I'm thinking hard about child birth and the
fact that the hospital you go to is your number risk factor for having major surgery and
so we as part of our work we created a consortium of 50 hospita ls across the country to
help us think about what was different from the hospitals that had, you know, they were
high performing and low performing and what are the lessons that we can extract and
scale.

Margaret Flinter: We've been speaking today with Dr . Neel Shah founder for Costs of
Care and co - author of Understanding Value Based Care published by M c G raw - H ill .
You can learn more about his work by going to Cost of Care.org or find him on Twitter
@Cost of Care, Dr. Shah thank you so much for joining us on Conversations on Health
Care today.

Dr. Neel Shah: Thanks so much for having me.

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Mark Masselli: At Conversations on Health Care we want our audience to be truly in the
know when it comes to the facts about health care reform and policy. Lori Robertson is
an award - winning journalist and Managing Editor of FactCheck.org a nonpartisan,
nonprofit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori what have you got for us this week?

Lori Robertson: Donald Trump claims that a 25% average increase in premiums on the
Health Care.gov exchanges announced by the Obama Administration was a "phony
number" he instead sighted increase of 60, 70, 80% but Tru mp just as easily could have
cherry - p ick increases in the sin gle digits. The fact is the administrations report shows
wide variation for the change in premium that variation ranges from a 116% average
increase for the second lowest cost silver benchmark plan for a 27 year old in Arizona to
a 3% average decrease for the plans in Indiana. There is a mere 2% average increase
in the swing state of Ohio with a 53% average hike in neighboring Pennsylvania. It all
adds up to an average 25% increase across the 38 states on Health Care.gov from
2016 to 2017. The median in crease is 16% that's without factoring in government
subsidies, but in presidential campaign appearances in Florida Trump claimed the 25%
average increase number was "so wrong" and that quote they know that's not true.
What is true is that some plan sold on the Affordable Care Act exchanges are expected
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to go up considerably for 2017. As the October 24 report release by the Department of
Health and Human Services shows there are three states with average increases for
benchmark plans above 60%. More st ates likely have individual insurance plans that go
up that high even though the average increase across all plans is much lower. For
instance, the HHS report shows the average increase for the benchmark plan for a 27
year old in Texas is 18% but there is wide variation within the state. In Dallas County
the average in crease is only 7% but Medina County which include San Antonio the jump
in nearly a doubling. Tax credits change what many consumers will actually pay 84% of
the 10.4 million Americans with market place coverage in the first half of 2016 received
tax credit, those put a cap on the amount in individual must contribute towards
benchmark premium based on income. The wide variation in premium changes among
states and different individuals circum stances for those buying their own coverage
under the Affordable Care Act shows that a nationwide average increase doesn’t tell the
whole story, but that doesn’t mean the number is phony, and that's my fact check for
this week I'm Lori Robertson Managing E ditor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact, that you wou ld like checked, email us at
www.chcradio.com. We will have FactCheck.org's Lori Robertson check it out for you
here on Conversations on Health C are.

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Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a par t of our communities and to everyday lives. Club foot is one of the most
common childhood deformities in the world a condition that in the past was not
correctable without the intervention of expensive and invasive surgeries. In low
resource parts of the world access was nearly impossible and as a result club foot is the
leading cause of disability in the developing.

Chesca Colloredo - Mansfeld : The effects on the child was devastating it also has an
incredible impact on the mom, these kids have to be taken care of and often the mother
is blamed for having a child with any kind of a problem as well as having a child with a
disability, so devastating for the whole family.

Mark Masselli: But a breakthrough treatment called the Ponseti Method has changed
all of that. Chesca Colloredo - Mansfeld was an employee at the University of Iowa
where this new noninvasive inexpensive intervention was develop which corrected the
problem in a series of months often before child even begins to walk.

Chesca Colloredo - Man sfeld: The health care provider gently manipulates the tendons
and ligaments in the foot and move the foot about 10 to 15 degrees and then places the
feet in a long leg plaster of paris cast. That cast is on for one week and then they
repeat the process and they just gradually move the feet.

Mark Masselli: She and her colleagues founded Miracle Feet a nonprofit organization
that identifies children throughout the world born with club feet who can be treated for
about 250 dollars per child, a tiny fracti on of what the surgery would cost. Today
Miracle Feet supports over a hundred clinics through partnerships with 25 different
partners in 12 different countries. Already having given thousands of children in the
developing world the chance to walk, run, p lay and to grow into productive adults.
Miracle Feet has earned numerous awards for its innovative treatment design and its
ability to be easily deployed in low resource setting.

Chesca Colloredo - Mansfeld: They have to sleep in a brace at night, the one that we've
made is made out of plastic, we came up with a brace that -- the shoes clip on and off
it's adjustable, the angles are fixed and we can produce it for 20 dollars. So we've
essentially come up with a design that enables us to do everything the U S brace does
but for a fraction of the cost.

Mark Masselli: Miracle Feet providing a low cost treatment for children born with club
foot around the world, giving them a chance to live active and fully productive lives now
that's a bright idea.

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Mar garet Flinter: This is Conversations on Health Care, I'm Margaret Flinter.
Mark Masselli: And I'm Mark Masselli, peace and health.
Conversations on Healthcare, broadcast from the campus of WESU at Wesleyan
University, streaming live at www.wesufm.org and brought to you by the Community
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