Next Generation is a BWH Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This month’s column is written by Ravi Parikh, MD, a third-year resident in the Department of Medicine.

Ravi Parikh, MD

Harvard Medical School taught me about costs in a general sense. I took courses in health policy to learn about health insurance. During a year off from medical school, I enrolled in classes at the Harvard School of Public Health and the Kennedy School of Government, where I learned about health economics and quality improvement. These classes all offered general systemic perspectives on costs. As a resident, my experience at BWH has shown me how the hospital is committed to lowering health care spending and costs. For example, many of my attendings on the inpatient general medicine service have a keen understanding of the costs of different medications. They focus on utilizing low-cost, high-value imaging and medications that have the best evidence base for treating the condition at hand. Training under such mentors is remarkable, especially as I am about to enter a fellowship in hematology/oncology, which can be associated with high-cost therapies.

Other hospitals have experience cutting costs in other ways, such as labeling electronic medical record orders with dollar signs to indicate high-cost tests and procedures and revising treatment protocols to emphasize low-cost interventions.

But as a resident in the Division of Internal Medicine and Primary Care, I often see a very different side of health care costs – from the patient’s perspective. I practice primary care in the Phyllis Jen Center, which has a high proportion of low-income patients on public insurance. I cannot tell you the number of times I have seen a patient discharged from the hospital on a high-cost medication, or prescribed a high-cost treatment from their physician, only to come back to the clinic unable to afford the medication. This is primarily because physicians are unaware of what patients’ insurance covers.

These patients don’t often see the benefits of our hospital’s efforts to cut costs because oftentimes efforts to cut costs are viewed from the hospitals’ and health systems’ perspectives – not from the patients’ perspectives.

Putting Pen to Paper

Mentors of mine, Sachin Jain, MD, MBA, FACP, (a former BWH resident) and Arnie Milstein, MD, noticed a similar discrepancy between institutions’ and patients’ perspectives on costs. Without acknowledging these perspectives, health care reform efforts, like the ones we are dealing with now, are unlikely to lower costs in a meaningful way. We realized that medical school and residency – seminal periods in a doctor’s life where we learn how to practice medicine – were opportune times to teach residents and students about the nuances of health costs. With good training on cost stewardship, physicians could practice high-value, low-cost care that lowered patients’ health care costs – regardless of the external environment.

Dr. Jain, Dr. Milstein and I researched efforts by other institutions to teach a more patient-centered view of costs, and found that there were enough examples out there that could be summarized in a short perspective article. We decided to write a short piece together summarizing the problem of different perspectives on costs and potential solutions; the piece: “Getting Real About Health Care Costs – A Broader Approach to Cost Stewardship in Medical Education,” was recently published in the New England Journal of Medicine.

It took close to four months to gather literature, put together an outline, write a draft, solicit revisions and ultimately hit the “submit” button. We went through five or six drafts, evolving the piece from something broadly focused on educational policy reform to more of a practical tool for clinicians and educational reform. Having two leaders and luminaries in the fields of health policy as co-authors certainly helped!

Ultimately, what I learned from them and the writing process was this: To be cost-effective, we as residents should be asking our patients about the costs they incur – not only for the costs of their medicines or treatments, but also costs of driving to appointments, taking off work and accompanying their family members to medical visits.

BWH is an exemplary institution for clinical teaching, and I feel fortunate that I’ve also been asked to think a lot about costs in health care.

In our NEJM article, we propose several changes to give future physicians a more comprehensive perspective on health costs. For example, policymakers and payers could encourage reforms in payment and health insurance design that align the economic interests of patients, providers and other stakeholders. Another example is that educators could provide opportunities for trainees to see the realities of patients’ lives with home visits and patient shadowing.

It’s time to get real about health care costs.