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What role should physicians play in discussing the financial impact of treatment decisions, and how can they better manage these conversations?
When David Margolius, MD, realizes that a patient is fretting about a medication’s price tag, he’ll pick up the phone, likely with the patient right there. As he makes the gauntlet of calls to several pharmacies, asking them to price the drug based on insurance coverage, he’ll proceed with his exam of the patient.
“Because I know I’m going to be on hold half the time,” says Margolius, an internist at the University of California, San Francisco, “I say [to the patient], `Let’s talk to the pharmacy together.’ I feel like it helps to builds the team spirit with me. That we’re going to figure this out together.”
Footing the medical bill, a perennial challenge for those lacking insurance, is increasingly becoming a source of stress for insured patients, as high-deductible plans proliferate. By 2014, 20% of Americans with employer-provided insurance were enrolled in these plans compared with 8% just five years earlier, according to an annual survey from the Kaiser Family Foundation and the Health Research & Educational Trust. Hefty deductibles also are frequently part of plans sold through the Affordable Care Act exchanges.
By late 2014, one-third of Americans reported that their out-of-pocket costs had increased “a lot” in the “past few years,” according to a CBS/New York Times poll of 1,006 adults. The vast majority of those surveyed, 80%, said they would prefer for their doctor to discuss the cost of a recommended treatment in advance.
But how does a doctor raise or address the sticky question of money, amid a time-pressed visit. Is that part of their role? Are there ways to handle the money piece of the equation so it doesn’t significantly extend the visit, or erode the doctor-patient relationship in some way? Doctors such as Margolius believe that cost sensitivity can be incorporated into a routine visit, and that ignoring the issue only places the patient in potential peril.
Margolius describes the example of a patient with asthma he treated during his residency who was struggling with a surprising degree of wheezing and shortness of breath. After some questioning, Margolius learned that she lacked prescription coverage, and so was spreading out the use of her inhaler, which cost roughly $150 for a month’s supply. Her clinically faulty rationalization, as he recalls it: “`If I could stretch out this inhaler over three months instead of buying a new one every one month, then I’ll be good.’”
Yousuf Zafar, MD, MHS, an associate professor of medical oncology at Duke Cancer Institute, says that his wake-up call involved a patient who refused to again take a particular chemotherapy drug. It turned out that the patient’s insurance didn’t include prescription drugs, so the first six weeks of the regimen had run up the patient a bill of roughly $2,000, he says.
In that case, there was an equally effective intravenous drug alternative that would have been covered under the patient’s medical benefit, Zafar says. “I could have prevented thousands of dollars in medical debt by simply asking him, `Do you have prescription drug coverage?’” he says.
Now Zafar asks more routinely about cost pressures, and believes other physicians are starting too as well. “There is so much evidence that patients are non-adherent because of costs,” he says. “We’re not doing patients any favors by prescribing them what we think is the best care possible, only to find out that they can’t afford it.”
Zafar advocates taking a matter-of-fact approach to raising costs, approaching the issue as a doctor might any other potential side effect of medical care. Only a few words are needed, without delving into the specifics of the patient’s insurance or monetary situation, Zafar says.
“Even a simple comment like, `This drug might be expensive for you. If you find that you’ve got a high copay, let me know and we’ll look for an alternative.’” In that way, Zafar says, “You open the door to a potential cost discussion down the road.”
Margolius uses a similarly open-ended approach. Instead of asking whether the patient misses any doses of medication, he asks how many days they miss each week. If they do acknowledge missing some, he’ll ask the patient to elaborate on why, a line of questioning that might bring to light any financial issues, he says.
Elsa Tsutaoka, MD, a family practitioner in San Francisco, typically waits until the patient raises financial concerns. Then she discusses cost where it’s clinically relevant. For example, if the patient has an uncomplicated urinary tract infection, she might mention that the urine culture can be costly, and is not vital. “If you discuss it with them, most patients will choose not to have it,” she says.
Similarly, if a patient needs an x-ray, Tsutaoka might steer them to a local provider that she knows costs less, although she doesn’t know precisely how much. She’s never had a patient with a high-deductible policy or without insurance become offended when she references cost, she says. “My sense is that they feel like you are tailoring their care to them.”
But don’t assume that you can rely on the patient to initiate, says Zafar, who coauthored a study looking at communication involving 349 cancer patients. His findings: 52% of patients wanted to discuss out-of-pocket costs, but only 19% had done so, according to the study, published 2014 in the Journal of Oncology Practice.
Data from a larger survey of 2,099 adults conducted by the non-profit Altarum Institute in 2014 highlights a similar communication gap. While 89% worried about unanticipated medical bills, just 56% reported that they had ever asked their doctor about the price tag.
Still, there’s some indication that patients remain conflicted about introducing cost into the doctor-patient relationship, says Susan Goold, MD, who coauthored a 2013 study that interviewed 211 insured adults in focus groups about cost communication.
Despite their worries about medical costs, the participants said they were reluctant to talk about money with their personal physician, even if it was their own wallet at stake rather than the insurer’s, Goold says. “Basically they want the doctors to just ignore for the most part the cost implications of their recommendations and decisions.”
But they did appear more amenable to talking to someone else in the practice, such as a social worker or someone in the finance office, says Goold, a professor of internal medicine and health management and policy at the University of Michigan.
At Duke, Zafar is able to tap the resources of an academic medical center, asking the pharmacists to run a drug that he’d like to prescribe through the patient’s insurance to calculate the bottom line cost. Then he asks the patient if that amount is feasible. “For some people, $50 a month is affordable and for others it’s not.”
In a private practice setting, the nurse can get a quick sense by adding a financial question to the routine clinical screening that’s conducted before the doctor walks in, Zafar says. “They can ask, `Do you have any problems affording the care that we’ve prescribed, or the medications that we’ve prescribed?”
Cost is also starting to be incorporated into some electronic health records, which can keep the issue on the doctor’s radar, Goold says. “Physicians often don’t recognize the cost of things like medications and referrals,” she says. “If you can show it to them maybe they would be, particularly when it’s the patient’s expenses at stake, more sensitive to that.”
Given the wide variations in price and insurance plans, doctors shouldn’t be expected to know precise figures for medical care, Goold says. But they should have a rough sense that treatment path A costs significantly more than path B, and the professional responsibility to alert the patient if the two approaches are clinically equivalent, she says.
Wendy Lynch, PhD, a research fellow at the Altarum Institute, questions why doctors can’t work a little harder to support their cash-conscious patients. Lynch, who is herself covered by a high-deductible plan, describes how she called around for the cost of a screening ultrasound and found that the price locally ranged from $196 to slightly more than $1200.
For these sorts of routine tests, she points out, doctors often have referred hundreds of patients through their practices. Why can’t the physician office, she asks, do some shopping themselves and identify sites that provide quality care at lower costs?
Lynch cites data from one Altarum Institute survey to illustrate a doctor’s influence. Just 7% of the participants disagreed with the statement that their doctor “would never recommend a test or procedure unless it was necessary.”
“If consumers trust their doctors so much that they believe that what they say is essentially gospel,” Lynch says, “then they have a very strong role to play in terms of helping people understand that there is a cost difference.”
What about when cost worries get in the way of preferred or even vital medical care? This circumstance can develop when a patient is on the verge of getting insurance, such as through a new job or waiting to become Medicare eligible, says Michael O’Dell, MD, a family practitioner in Kansas City, Missouri.
A patient without insurance might put off a knee replacement until reaching age 65. More clinically worrisome, O’Dell says, “I’ve had people delay follow up on a lung nodule or something like that until they become insured.”
O’Dell outlines the medical risks to the patient, and documents the conversation in the medical record, while still keeping the lines of communication open. “We have to be compassionate, and be kind and leave the door open for when they do come back,” he says.
Tsutaoka recounts a similar scenario that she encountered, in which a patient has a nagging cough and a history of lung disease, but is balking at the cost of the x-ray. She’ll inform the patient that she can prescribe an antibiotic in the short-term, but that she’d prefer the test to check if the patient has other problems related to the lung or fluid around the heart.
Sometimes she’ll give the reluctant patient an order for the x-ray, stressing the importance of using it, if the patient’s symptoms don’t improve. “It saves them another visit back that they’d probably have to pay for,” she says. “And it gives them permission to move along.”
Patients also should be given permission to call the practice if they hit an unanticipated bill, such as sticker shock at the pharmacy counter, Zafar says. “Give the patient an out by saying, `If you find that this prescription is too expensive for you, don’t fill it, let me know and we’ll see what we can come up with.”’
These sorts of price-related discussions are likely here to stay, if the trends involving high-deductible plans are any indication. The vast majority of employers, 82%, had planned to offer a high-deductible plan as one option in 2015, according to an annual survey from Towers Watson and the National Business Group on Health. For 30% of employers, it will be the only insurance plan available to workers.
In this emerging world of cash-on-the-counter medical care, Goold believes that primary care doctors have the advantage of being able to develop an ongoing relationship with patients. Over time, if cost factors are routinely acknowledged, then the patient hopefully will be willing to stretch to pay when an expensive treatment approach is recommended, she says.
“The problem is what we know from the research is that patients definitely decrease their use of services when it costs them more,” Goold says. “They’re not very good at figuring out which services they should decrease. I think that’s where they need doctors. To say, `You know, I know this is going to cost you more money, but it’s worth it. You really need this.’ ”