How to discuss care costs with patients

February 17, 2020
Keith Loria
Volume 97, Issue 4

A recent survey conducted by InstaMed, an online healthcare payments service, revealed that 93 percent of patients were surprised by their medical bill, including 61 percent who received a bill for more than expected and 50 percent who received an unexpected bill.

“This surprise and confusion stems all too often from a lack of communication between medical practices and their patients,” says Deirdre Ruttle, senior vice president of strategy and communications for InstaMed. “Patients are not usually aware of their responsibility until after a visit, which is unlike many other payment experiences where there is a clear price tag and an understanding of how to pay.”

But medical practices can remove the uncertainty in healthcare payments by communicating early with patients, setting expectations, and offering payment convenience. This includes talking about payment responsibility, insurance coverage and cost estimates, offering multiple payment options including online payments and automated payment plans, and enhancing patient convenience through electronic statements, email notifications and text notifications, experts say.

The cost conversation

David Belk, MD, an internist in Alameda, Calif., says there was a time when most discussions about medical costs centered around questions like “Will insurance cover this?” or “How can we get insurance to cover this?”

“As nightmarish as those conversations were thought to be, such questions do seem rather quaint and simplistic by today’s standards,” he says, citing discussions today of questions like, “What does covered even mean?” “Can I afford this test or procedure even if it is covered?” and “Would I be better off not even using my insurance and just paying for the medical test or procedure myself?”

Brian P. Sanders, MD, a family physician at About You Family Medicine in Atlanta, Ga., says he’s finding that fewer people are  shy about discussing cost of care.

“For folks that live paycheck to paycheck, the discussion involves how to save up to afford a more expensive but necessary evaluation or treatment or procedure,” he says. “Without these discussions, many patients would oftentimes not get any medical care or allow the problem to fester until it becomes a more expensive emergency.

Troy Russell, MD, a family doctor in Lynn, Mass., notes that for about half the medications he prescribes, patients will ask whether it is covered by insurance. He’s also asked routinely whether all the medications they take are absolutely necessary.

“Patients are often most concerned about costs of specialty medications like insulin, Remicade, and Xarelto,” he says. “My response is usually that we try to use generic medications first, try to use coupon programs like GoodRx and if that doesn’t work, we pursue prior authorization through insurance.”

Katarina Lindley, DO, FACOFP, a direct primary care family physician in Brock, Texas, says she discusses pricing and affordability with patients almost daily. For example, when she orders labs or imaging for patients, she helps them decide where to have them done.

Some patients prefer to pay directly rather than going through insurance because deductibles are so high.

“An example is, I can get labs for an annual physical for about $20, but with insurance it can be $150-500 if the patient has not reached their deductible,” she says.

The same is true with medications. Before prescribing, Lindley discusses with her patients if they can afford them. Such discussions are important, she says, because patients sometimes are embarrassed to say they cannot pay for meds and won’t get them filled.

“My job as their doctor is not only to help them recover from or control an illness but also to look at their overall health and at times that means financial needs as well,” she says. “All physicians should have these discussions with patients, because they may not be compliant and their blood pressure is still high because they could not pay for that third medication.”

Jeffrey Gold, MD, a pediatrician in Marblehead, Mass., notes that a typical discussion will find him showing a patient what lab test pricing is compared to what a typical hospital charges, using websites such as mymedicalshopper.com and healthcarebluebook.com.

“I once saved a patient $2,000 for a cardiac stress test by sending him to Derry, New Hampshire, versus our local hospital,” he says. “Obviously, this was a low probability test and non-urgent, and it took him two weeks to get a reply from his insurer as to what his out-of-pocket payment would be. But it was something that was greatly appreciated.”

Navigating the discussion

Russell routinely has his medical assistant screen for financial or social economic barriers to care so he’s prepared for where the conversation will go.

“Some patients are not interested in telling me these issues unless it is really bothering them,” he says. “Since my medical assistant staff are native Spanish speakers and culturally able to connect better with some patients, they are able to elicit this information a little easier.” They do this, he says, simply by asking if the patient has any questions or concerns.

Gold says physicians need to be open and honest, and not just say what the patient wants to hear. “Most people still don’t even understand what coinsurance, deductibles or networks are, and the conversations are still not as prevalent as I would like them to be, but definitely more common,” he says. “If you’re honest with them about their options, it can drive the relationship even further.”

Recommending resources

One of the most common questions patients ask physicians is where they can find help in reducing their out-of-pocket costs. Doctors say prescription drugs often are a good place to start.

“Most people believe that they’re getting a good deal from their insurance if they’re only paying a $5-$10 monthly copay for a generic medication,” Belk says. “They’re usually wrong about that.”

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