Physicians have responsibility to patients to talk about the cost of care, prescriptions
Going to the doctor in the United States is like dining at a restaurant where the menus don’t list prices. At this restaurant, the chef decides what you should eat, and someone else entirely calculates the bill. The chef is considered an artist unencumbered by financial details so he or she can focus on preparing the best food possible. Yet with no consideration of cost, the chef decisions could result in a surprising and shocking bill that you cannot afford and which potentially goes unpaid, bankrupting the restaurant in the process.
Many health care consumers face a similar dilemma: We want our doctors to make critical health care decisions and provide us with the best quality care, but we also increasingly want to be able to — though can’t always — find out from our providers how much that care will cost. Without price information or a culture that enables explicit exploration of financial factors, consumers have limited ability to make good decisions about how best to meet both their clinical and financial needs.
Physicians must start talking prices with patients
To help realize the promise of consumer-driven health care — in which sharing financial risk causes consumers to spend health care dollars more judiciously — physicians and other health professionals must start talking about cost with their patients. The path forward will likely require long-term cultural changes that normalize cost conversations; we should start this journey by training clinicians on why and how to engage with patients about health care costs.
The very notion that doctors can and should be responsible for communicating about costs with patients is anathema to traditional clinical training. An even greater obstacle could be that providers themselves don’t always know what health services will cost their patients. Costs are based on each patient’s insurance plan, whether the patient has and has met a deductible, what codes will be used to bill the service, and what charges the health plan allows. Not surprisingly, these conversations rarely happen.
Yet in a study published last month, we found even in the unlikeliest of settings — the intensive care unit — patients and their providers considered costs explicitly. Of the nearly 50,000 ICU admissions we analyzed, more than 4 percent had at least one note in their medical record documenting a cost concern or consideration. These notes revealed both people who had been unable to afford prescribed medications before landing in the hospital, and those whose prescriptions had to change because of cost constraints. Other notes also showed that patients at times stayed in the ICU longer than clinically necessary because of slow insurance approval to discharge patients to rehabilitation facilities. Still others could not get approval for recommended rehab at all and were sent home with “self-care instructions.”
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Financial concerns in health care encounters are a growing reality. Another recent study showed that even cancer patients do not necessarily take their medications as prescribed — or at all — due to financial barriers. Approximately 30 percent of people diagnosed with cancer in this study asked a doctor to prescribe a lower-cost medication.
“Cost is like the dirty secret of health care,” Heather Ross, clinical assistant professor at Arizona State University and nurse practitioner in cardiac electrophysiology, told me in an interview for my research on the consumer behavior in health care purchasing.
“Cost feels like it's ethically problematic and not pure,” Ross said. “I was trained to do that work completely agnostic to cost.” Instead, she explained, “My moral obligation as a health care provider is to prioritize quality and saving the life, curing the disease, optimizing the quality of my patient's life above all else."
Price is becoming an important part of care
Once in practice, though, Ross noticed patients to whom she had prescribed medications were not having the treatment response she expected. She realized her patients were cutting their pills in half or taking them every other day because of expense.
“That behavior … of totally ignoring cost, that is completely unethical because you're creating a situation that the patient cannot attain the health care that you are prescribing,” she said. Providers must, Ross believes, factor their patients’ economic realities as well as clinical needs.
I recently met with a group of medical students also pursuing public policy degrees. They told me that they have rarely initiated cost conversations with patients in their clinical training, and that they generally feel somewhat or extremely uncomfortable discussing costs with patients. Their training in this area is informal, based more on observation than structured curriculum. This gap needs to close. And it can, with deliberate training and use of tools and technology to make costs easier to access.
As patients foot more of the health care tab, they will likely look to their providers for help in making good health care decisions, including choices they can afford. Just like a great chef may prefer to focus on flavors over finances, health care providers may not want to get involved with costs in individual patient encounters. But the restaurant that ignores customer expectations to factor cost in their meal selection won’t keep many satisfied patrons.
So, too, must health care providers reorient their roles to acknowledge patients’ financial concerns. Health care providers who become consumer allies — willing to talk about and even tackle the challenges of price transparency and health care affordability — will find they have more satisfied and trusting patients.
Deb Gordon is a senior fellow at the Harvard Kennedy School’s Mossavar-Rahmani Center for Business and Government. Follow her on Twitter: @gordondeb
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This article originally appeared on USA TODAY: Doctors, providers must provide patients treatment cost information
