Patient costs when making medical decisions

At my office we provide care for a fair number of patients without medical insurance. Sometimes we are faced situations with no good options.

At a patient visit, often times the diagnosis is not clear without doing some diagnostic tests other than the history and physical exam. Many of these tests are ordered from sources outside the office, where I have little or no control over the cost of the test to the patient. In other than straightforward visits, where the diagnosis is apparent and treatment can be recommended from what is learned at the visit, these tests can cost more than the charges from my office.

The old saying, “The most expensive medical instrument is the physicians pen,” is true in these cases. The dilemma is that I know ordering these creates a real problem for some of my uninsured patients. When do I order the CT scan to look for an atypical presentation of appendicitis in the 23-year old woman who probably has a simple ovarian cyst, but could have a ruptured appendix? When do I order the MRI looking for the unlikely but possible brain tumor in the 25-year old with severe headaches for 6 weeks who likely has stress headaches?

We use a program called “Simple Care” to avoid contractual issues with our third party payers, both governmental like Medicare and Medicaid, and private insurers. Simple Care patients are required to pay at the time of the visit, saving us the need to bill, collect, and code for the visit. We have convinced our lab and primary radiology referral sources to discount their services to our Simple Care patients.

This works well for most visits, but when a patient has a potentially serious problem where the standard of care is to order tests outside the office it gets complicated. The patient may be able to afford the $50 or $60 dollar visit, but the $1500 CT scan or MRI, or the several hundred dollars of lab tests may be another matter altogether. Few of my specialist consultants discount fees for cash paying patients, and these patients often do not have the cash to pay at the time of service for more expensive tests, consultations, or procedures.

In some cases I can feel comfortable using time, therapeutic trials, and inexpensive tests to get to a diagnosis of exclude more serious problems. Other times the diagnostic possibilities include problems so serious that delay in diagnosis puts the patient at such risk that I have to strongly request they spend the money, of more often incur the debt to get the tests done.

It is easy to argue that a physician just needs to provide the same level of care for the uninsured patient as the insured patient, but in the world we live in the consequences of subjecting the patient to debt payments for months or years, or possibly bankruptcy has to be taken into account. The chances of a negative test are usually higher than the chances of a test showing the problem you are looking to exclude or confirm.

In these cases I sometimes second guess myself. Could I have safely avoided exposing my patient to the expense of these tests that turned out negative? I don’t have an answer for this dilemma. I try to give a recommendation, present options, and involve the patient in the solution.

Still I struggle often with the responsibility of urging a patient to get testing I know they can neither afford to have done or to not have done.

Edward Pullen is a family physician who blogs at A medical blog for the informed patient.

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  • Dr Lemmon

    If I have to get the test I will.

    In your example of the possible brain tumor, a delay in diagnosis, assuming a normal neuro exam is not a concern. Treat for the tension headaches and have close follow-ups. If symptoms do not resolve completely then you can obtain your MRI. Document fully.

    A possible ruptured appendix though, I guess you have to spend the money. But if WBC normal, even that might be watched if a surgeon examined the patient too.

    I saw a patient in excruciating pain the other day with a history of prior renal stones, her urine was dirty. No gross hematuria. Based on her exam and history I concluded I could wait 24 hours with getting CT scan and treat for UTI. She had no insurance. The following day the she was fine. I must say it tested my nerves.

    Just a few thoughts, I know it is tough. I have wasted my share of money on negative tests out of fear and insecurity and also to do the right thing.

  • Drew

    For someone who has never had any major health issues, or much interaction with the medical universe, I’ve never given the stress the medical practitioner is going through during the diagnosis process much thought. Thank you to Dr. Lemmon and Dr. Pullen for giving me a different perspective and appreciation for what you and other medical professionals do.

  • Ed Pullen

    I had not really thought about the stress issue, just trying to do the right thing. Sometimes it is just hard to figure out what is the best of suboptimal choices.

  • H

    I pay 20% of my medical costs. I have never had a physician consider the cost of tests. The worst was a doctor that belonged to a hospital based medical center. $1200 hospital fee for 2 minute procedure plus the $500 physician fees. If I had known the cost, I would have declined treatment. I decided I couldn’t afford the follow-up.

  • rezmed09

    So much of our cost issues would be reduced if patients knew the cost of every test and treatment ordered before they got the test and had to pay some percentage of that cost.

    Right now it is all a costly game.

  • Doc99

    Med School needs to incorporate more “patient care,” and less “Disease Care,” perhaps in the Fourth Year. Similarly, postgrad programs need to incorporate this as well. When the patient has a “skin in the game,” this process becomes eminently logical. Problems creep in when patients perceive their care is “free.”

  • Dr. Matthew Mintz

    The factors that go into deciding whether to perform a diagnostic test or not include likelihood the test will make the diagnosis, likelihood the test will rule out something of serious concern, what we think the patient may have (pre-test probability), risk of the test (pain, radiation, etc.), cost of the test, and liability. Hopefully physicians think of costs for all patients and don’t order chest CT’s when CXR’s will do. However, Dr. Pullen brings up the challening issue of how the patient’s ability to pay will modify the thought process. We are more likely to modify our pre-test probability when the patient needs to pay for the test themselves. The other important issue though is liability. I am not aware of how Simple Care works, but I hope that either these patients sign something saying they won’t sue or that you explain/document that you would normally order this test, but won’t because it’s not that likely to be helpful and it’s going to cost the patient a lot of money. I am pretty sure that uninsured patients have the same right to sue as insured patients. This makes the decision even more difficult, because while you may be trying to save the patient from an uncessary expense, if the outcome does turnout badly, you might be only hurting yourself.
    Regardless of the solution (left single payer/right tax deductible HSA’s), we need to get everyone covered and we need to reform our malpractice system. Otherwise, these dilemmas will become more common ocurrences.

  • stargirl65

    I find uninsured patients to be the riskiest. They often cannot afford testing or appointments with specialist. It puts me at high risk should something go wrong. I basically try to ignore the fact that they don’t have insurance and make decisions just as I would for anyone else. You will make mistakes when you try to make decisions based on insurance or not. The patient can decide if they want the test. That being said, I try not to order unnecessary tests in genera. Sometimes though you just need to CYA.

  • IVF-MD

    Wouldn’t you expect costs for tests (and all medical care) to go down if more competition were allowed? That would be nice.

  • Martin Young

    The problem with medicine is that everything looks so simple in HINDSIGHT!

    The adage “hindsight is 20/20 vision” is more true for medicine than in almost every other field.

    Lawyers and disgruntled patients are particularly prone to this way of thinking.

    We are “damned if we do, and damned if we don’t” so often it becomes commonplace.

    I follow my instinct, warning patients that an expensive test’s negative result is what they really want to hear, and buys them peace of mind.

  • imdoc

    I think IVF-MD is absolutely right. We have seen patients able to afford cash-based physicians. Now if diagnostic tests could also be more readily available on the same basis we will see more reasonable pricing. I know of a few independent centers around the country which provide radiology services for a fraction of the existing market price. These are centers which take only cash. Think about it – where do you see an expensive CT or MRI running 24/7 with price tiered by time of day? Our whole system could improve if we could only believe more in the free enterprise system; that made this nation great.

    • Healthcare Observer

      ‘Think about it – where do you see an expensive CT or MRI running 24/7 with price tiered by time of day? Our whole system could improve if we could only believe more in the free enterprise system; that made this nation great.’

      This is dangerous comment. US healthcare is already fragmented too far without setting up yet more ‘choice’ that in reality means lack of multidisciplinary integration and learning among physicians. That way leads to the awful problems the New York Times has been reporting with complex radiation treatments administered away from the supervision of an integrated oncology team.

      • IVF-MD

        Different patients value different things more. Some are willing to pay super high prices in exchange for your “multidisciplinary integration and learning”. Other patients just want an accurate diagnosis and a safe procedure and would be willing to put up with the risk of a little fragmentation in exchange for lower fees and better customer service. So I don’t understand why you are against them having choices. Why begrudge them the freedom to get an accurate diagnosis with a safe procedure and good customer service at an affordable price as long as they don’t begrudge you the opportunity to pay higher fees in exchange for the “multidisciplinary integration and learning” that you claim to want. You have no more right to ban them from what they value than they do to ban you from what you value.

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