The most common operation in the U.S. is the Cesearean section, and the single biggest variable that influences a woman's chance of having a C-section is the hospital she chooses to deliver her baby. This physician wants healthcare leaders to know there is something fundamentally wrong with that.
Neel Shah, MD, an assistant professor of obstetrics, gynecology and reproductive biology at Boston-based Harvard Medical School and associate faculty at Ariadne Labs for Health Systems Innovation, has made it his mission to find out how hospitals can improve rates of low-intervention childbirth. As a medical student, Dr. Shah launched Costs of Care, an NGO with a global reach that helps provide insights for clinicians to provide better care at lower costs. He was previously named one of Becker's Hospital Review's "40 of the Smartest People in Healthcare."
We caught up with Dr. Shah to discuss his C-section mission and his work to drive down the costs of care.
Editor's note: Responses have been edited lightly for length and clarity.
Question: Your research at Ariadne labs focuses on overtreatment in childbirth, and in particular C-sections. What first sparked your interest in investigating C-sections?
Dr. Neel Shah: In my residency I saw C-sections had become very normalized for clinicians. When I took on a faculty position at Harvard, I looked for opportunities to improve childbirth. I zeroed in on C-sections as biggest lever I could pull.
C-sections are the most common major surgery performed on human beings anywhere in the world and the most common in the U.S. They have become 500 percent more common over the last generation of moms. We really have no idea why rates are skyrocketing. Not only are they really high, but it's hard to believe 1 in 3 humans need major surgery to be born. There is also incredible variation in C-section rates from hospital to hospital. It ranges from 7 to 70 percent of births, which indicates the greatest risk factor for a woman to have a C-section may be the hospital she goes to — not her own risks or preference — but which door she walks through.
Additionally, about half of C-sections are not necessary in retrospect. As many as 20,000 surgical complications could be avoided that cost $5 billion and a lot of unnecessary pain and suffering.
Q: What are the biggest obstacles to reducing C-section rates in hospitals?
NS: Both the solution and the barrier is something at the hospital level. The fact that C-section rates are so different from place to place means there is something going on at the hospital level we don't understand. A range of 7 to 70 percent of births is so spread that on one hand, that's really messed up, but on the other hand, we already know some people have figured what the solutions might be. We have to look at the people who are doing well and spread those ideas to other places.
Through another lens, looking at the ways hospitals are managed, labor and delivery floors are where 99 percent of babies are born in the U.S., and they are also the hardest units to manage in the hospital. The reason is, unlike other parts of the hospital, the unit operates under incredible uncertainty all the time. They don't know how many patients are going to show up and once the patients show up, they don't now how long it will take. Labor can be short or long and you don't know who will be healthy or suddenly need acute surgery, and the unit may need resources to operate immediately.
Which patient should go to which room becomes really complicated. It's like an air traffic control problem that shifts from one hour to another. Managers have to learn how to be good on the fly and learn from their predecessors, but they don't know how their peers approach these challenges. How labor and delivery units are managed is different from place to place, and we have never characterized what those meaningful differences are. That's the work that will show us what makes a high-performing versus a low-performing hospital on C-section rates.
Q: You are also the founder of Costs of Care. How has the organization evolved since it first launched?
NS: We started in 2009 when I was a third-year med student caring for a lot of patients who didn't have deep pockets and struggled to afford care. Everyone around me was making decisions on their behalf that impacted how they had to pay, and I realized we could make different decisions that lead to the same health outcomes but are more accountable in terms of cost.
We benefitted from the timing. In 2009, healthcare reform was top-of-mind. The name 'Costs of Care' wasn't particularly creative, but people were Googling that thousands of times a day in 2009. Because of the name, we got a lot of Google hits and pretty soon we were the No. 1 hit on Google. To this day you get our website first and HHS' second.
When we started, we were largely an advocacy organization focused on leadership development, building the will for change in the profession and training physicians. We wrote a whole textbook on how to think about costs while caring for patients. We created education modules to shift professional will and teach skills physicians needed to care for patients.
Over the last six years, the world has been shifting with us in positive ways. We still care about learning and advocacy, but it's less of the main focus now. The policymakers have also taken this up with incentives to think about value. We are starting to shift from advocacy to an implementation organization that designs, tests and spreads solutions.
Q: What have you found to be the most effective strategies in teaching physicians to consider costs?
NS: You have to be really clear about the piece they own. Usually people talk about healthcare costs in abstract terms, like they account for 18 percent of GDP. Most people know that's a problem, but no one goes to med school to change GDP. We need to reframe the cost conversation within the doctor-patient relationship, forgive the things they are not responsible for and focus on the things they are.
If you take a picture of a generic American medical bill and show it to physicians, you will find several things wrong. Within 10 seconds, this will be the longest a doctor has ever looked at it. Prices are inflated and arbitrarily determined and doctors will throw their hands up at it. You need to tell them you understand it's not their fault and forgive them for that, but then highlight the times they are adding cost without helping the patient get better. Those instances are directly in their wheelhouse and they need to own that.
Q: What would your best advice be to hospital leaders who want to help physicians be more cost-conscious?
NS: The same thing — Keep the focus on the patient, as opposed to healthcare costs in general. The cost to the patient is different than the cost to the hospital, and the thing clinicians care most about is the cost to the patients they are caring for.
Leaders need to show physicians thinking about costs is not skimping on necessary care, and maintain focus on the part of the problem that physicians own. Physicians may say patients are demanding that they need this, or voice concerns about medical malpractice, and leaders need to acknowledge that. Yeah, sometimes patients will say that and yeah, medical malpractice is tough, but it's not the whole ballgame.
Q: What is your take on how healthcare has played out in the election so far?
NS: First let me say that Costs of Care is very intentionally nonpartisan. Of course politics affect everything in healthcare, but we try really hard to make sure we present our solutions in a nonpartisan, neutral and objective way.
The way it has played out is Obamacare has become a lightening rod for the Republican side. It's more neutral on Democratic side; there's a little bit of a spat between Bernie and Hillary about whether you start all over or do single payer, but they are essentially on the same page. There are real legitimate pros and cons no matter which side you take.
I would say if you are against the ACA, tough nuggies. It was held up in highest court in the land twice. If you are for it, you have to stand by it, and understand we didn't make healthcare any more affordable for Americans. For many of them we've made it easier to purchase insurance — but that's just your ticket to the show.
Most Americans have high-deductible health plans and the average deductibles are several thousand dollars. No matter who you are, that's real money. Tests and treatments that don't make you feel better are eating into people's wallets. More people are insured, but insured with the worst insurance and still struggling to afford care. I would argue in 2016 healthcare is the least affordable it has been in the last half century.
There have been lots of benefits. My own younger brother wouldn't have a mechanism of getting insurance — he's in his 20s and doesn't work for a big employer. I see the benefits in my own patients because being a woman is not a preexisting condition anymore. These are big forms of social progress, but it's an incomplete solution and we still have more to do.
The key for the Becker's audience in thinking about healthcare reform is to be careful not to conflate two things: payment reform and delivery reform. The way money flows happens in the halls of Congress and delivery reform happens in the halls of hospitals. What we have to do is figure out what to do differently in our hospitals and clinics. If you have created the carrot and stick, your job isn't done.
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