Bedside manner may need to include cost of care discussions

by Dennis Grace

For years, if you asked for a recommendation for a physician, the answer included some mention of bedside manner.

I mean, we’re human beings first and patients second, so we think it’s great that she’s a brilliant doctor, but is she pleasant? Is she respectful and patient? Nobody wants to work with a know-it-all, especially one who gets to hear about our bowel movements and stare at our genitals.

These days, knowledge of the cost of care is becoming an important component of bedside manner. Most anyone over forty has had the experience of a doctor cheerfully prescribing a drug that would cost fifteen dollars a day or blithely ordering a test that costs as much as a used car. Until 1998, apparently, doctors just weren’t taught to take costs into consideration. Before that time, doctors who did know about the costs were real go-getters.

Fortunately, as detailed in an article in the New York Times that kind of insensitive behavior should be going the way of the dinosaurs. Doctors are learning that they have to know the cost of the procedures and drugs they order, and understand the impact of those costs on their patients. The bad news is that this knowledge is getting out sloooowly. Many physicians simply don’t have the message yet.

So, what can you, a knowledgeable and cost-conscious patient, do to be sure your doctor is in the know on the cost of drugs and surgery? Well, you could come right out and ask how they factor costs into their work, but with office visits being shrunk down more and more these days, such casual conversation rarely seems to fit the schedule. Instead, you might hit him where it matters. When he prescribes a drug or orders a procedure, just ask, “Is this going to be expensive?” Better still, ask how much it will cost. A cost-aware doctor will answer your question or at least politely excuse himself and go find an answer.

And the rest, the not-so-cost-aware? Well, they’ll say something like, “You’ll have to ask the pharmacy (or lab, or surgeon).” For something complex, they might say, “Well, my portion will be covered by your insurance, but I don’t know about the rest.” The really snotty, easily-offended, know-it-all physician will say something like, “How can you ask questions like that when we’re talking about your health?” Most of these answers are warnings that you need to consider other options (and when I say “other options” I mean “other doctors”).

And if the doctor tells you the cost, and it’s too high? Ask about alternatives. If it’s a drug, ask about generics. If it’s a test, ask if a simpler test won’t provide enough information. Before you go in for an MRI or CT scan, know what additional information the doctor expects to gain from the test. Is that gain worth the cost of the test?

If you’re really lucky, as is often the case with my pulmonologist, he’ll give you free samples. (Disclaimer: Doctors rarely offer free samples of MRIs.)

Dennis Grace is co-founder of MedicalBillDog.com and blogs at The BillDog Blog.

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  • Vox Rusticus

    I don’t agree with this writer. It really isn’t my place to counsel a patient on costs of testing. That is a matter for the laboratories, imaging centers and those who perform testing to provide. It has nothing to do with “bedside manner” and it is –and I say this generously–a tortured turn of logic to try to say that it is. It really seems that the writer wants to hang this information-providing responsibility on someone and the doctor seemed the convenient person to choose.

    First, I do not establish the prices of the imaging centers or pharmacies. Second, I am not privy to their contracts with third-parties or to the discounts those entities negotiate.

    If I recommend a test, it is (I hope) because I think the test result will at least advance the diagnostic process if it does not make the diagnosis outright. If the test or its result does not satisfy that end, then I should not order it at all, regardless the cost or whether the patient requests the test.

    I wonder if the writer is a third-party shill, pretending to make costs counseling a medical matter when it really isn’t.

  • Patient Advocate

    Dennis you are mistaken. You are first a consumer, then a human being and then a patient, according to your logic.

    Doctors cannot possibly know what everything costs. That is so ridiculous and lazy to say. Why is it my job to tell you how much you will have to pay the surgicenter or pharmacy? You are the consumer, call them and shop around.

    If you ask me how much the EKG I just ordered or the shot I’m about to give you costs, well then of course I should be able to tell you exactly how much that will cost you, because it’s done at my office and my staff can verify your insurance and tell you to the penny what the contracted amount will be.

    I can do my best to give you a rough estimate of other costs, like how much is your chemo going to cost, how much will this knee scope set you back, or how much will that bronchoscopy run you, but those are very rough estimates to answer a very unfair question.

    If I see thirty patients a day, the amount they pay the hospital, imaging center or pharmacy (all places I don’t work at) for their Xray, MRI, antibiotics, copay, etc (all things I don’t bill for) could very easily all be different depending on if they have Medicare, medicaid, tricare, cash pay, or one of the gazillion insurance plans or medicare supplements. And how do I know if you’ve met your deductible or if the imaging center or hospital is ‘in network’? The patient (consumer, that’s you in your example) agrees to and signs up for their insurance. It’s between you and your insurance company. I don’t know how much your insurance is or isn’t going to pay the radiologist and hospital when I order a chest Xray because you are in my office with a fever and coughing up green.

    The patients (consumers) ask me these questions and I try to give them a reasonable ballpark of the costs, with the caveat that I don’t know what they have signed up for with their insurance. For instance, a patient called me this weekend about his daughter with recurrent strep throat, and I told him the antibiotics I was calling in were newer and may cost more based on his copay set up, but since she’d failed the generics I thought it was the best option. Another time, a diabetic medicare patient was having shortness of breath and chest pain in my office and refused an ambulance because he didn’t want to pay for it. I told him he couldn’t worry about the costs right then, he needed to deal with it. I guess according to you I must be a snotty, easily offended, know it all? (I loaded his butt in my own car and drove him to the ER…he left AMA yet he was and remains one of my favorite patients, tough old coot!)

    The bottom line is these costs you are asking about are not your doctor’s responsibility. It’s unfair and lazy to pin this on the doctor. Check with your insurance plan to see what kind of costs you are looking at.

  • http://www.medicalbilldog.com/blog Dennis at MedicalBillDog

    Looks like I hit a nerve.

    I love it when doctors give examples to demonstrate that they aren’t personally guilty of a bit of wrongdoing while at the same time insisting that it really isn’t wrongdoing.

    I also love Vox Rusticus’s turn of a phrase: “If I recommend a test…” That’s hilarious. I’ve never heard a doctor recommend a test. They just assign them. Some of them even tell you where to get the tests.

    And, sorry, Vox, I don’t offer cost counseling. I just advise my clients to avoid doctors who “recommend” tests without having the faintest idea what they cost.

    • Vox Rusticus

      Will that cerebral MRI with and without contrast cost $700, or $1100 or $3000? How much extra will an angiogram be if ordered with the above? Will the patient’s Blue Cross have a co-pay for the study? Will the “cost” be the same for the Blue Cross traditional patient or less for the Blue Cross HMO patient? Will the Aetna patient get the same “cost” as the United Healthcare or Medicare patient? That is one test. Imagine how many people I would have to hire to answer those questions, for tests I do not perform, never mind pay for. To me, those are insurance issues best answered by either the people who run the insurance plan or the people who actually bill for doing the test, but not me.

      Dennis, you wrote:” I don’t offer cost counseling, I just advise my clients to avoid doctors . . . ” That is a pity. If you actually did provide a service to map out a best cost route to a plan for a patient, you might be adding value.

      • http://www.medicalbilldog.com/blog Dennis at MedicalBillDog

        So I’m a shill if I offer counseling, but it’s a shame if I don’t? Look, Vox, you’re the one being ridiculous. You know roughly what a CT-scan is going to cost, pre-insurance. You should also know what adding contrast to the procedure will cost. I know the insureeance throws another loop in the whole financial knot and that everyone’s insurance is different. I’m not asking you for a complete and accurate accounting of every procedure. I’m just saying it’s wrong to order a test (and that’s what every doctor I’ve ever seen has called it–ordering, not recommending) with no regard for the financial burden you’re placing on your patients. I never said you had to know how every damned insurance company will pay or not pay for every damned test.

        By the way, on the earlier matter, of the gent you drove to the hospital: good for you. If you hadn’t–if you’d just left matters at “don’t worry about that right now”–then I’d have called you self-righteous. Driving him makes a huge difference. Of course, you already know that.

        • Vox Rusticus

          No, I really don’t know what the CT is going to cost, either “pre-insurance” or post-insurance. I have nothing to do with setting the fees for the radiology centers, I don’t get pricing information from those centers (they aren’t sharing their pricing or contracts rates with me–that is usually regarded as confidential information by most businesses, if you didn’t know that.)
          I could guess, I suppose, but that isn’t information. The same is true for laboratory studies or anything else I do not sell.

          Patients who want to know the answers to those questions ought to ask themselves.

    • Sarah

      “I’ve never heard a doctor recommend a test. They just assign them.”

      Okay, and either way you, the patient, get to ask questions or say no thanks. I’ve done it with a recommended test, and I’ve done it with an “assigned” test (where the office called and said, “You have to do this!” Well, no, I don’t).

    • Patient Advocate

      I understand your frustrations regarding costs, but your anger towards doctors is misguided. None of this has anything to do with bedside manner. Patients have a bedside manner too.

  • Dave

    It’s darn near impossible to know how much a patient will pay for any given drug. Each insurance is different, and what a patient pays often has no relevance to what a drug costs. I’d prefer my physician to keep up on his pharmacology rather than memorize archaic insurance payouts. That said, I don’t think a doctor can go wrong with prescribing the “true” cheapest option for a given disease (amoxicillin/penicillin for group A strep, etc.). Not only will such a decision drive down healthcare costs (even if it is through saving the insurance company money), but should also have the effect of preventing antibiotic resistance as newer antibiotics are not overused.

    • http://www.medicalbilldog.com/blog Dennis at MedicalBillDog

      Yep. Damn near impossible. It’s not impossible, however, to know that the unmitigated costs of the more expensive drugs. I never once said anyone had to provide exact cost breakdowns.

  • Michael F. Mirochna, MD

    it all sounded good until the “free” sample part. The free samples are not free. Why do you think patients wind up on expensive medicine in the first place? The drug reps bring the office lunch and the doctor samples and whisper in their ear how much better this newer drug is because of certain lab studies that may or may not ever have any clinical benefit. That “free” sample isn’t free and until that time, the article was quite reasonable.

    • http://www.medicalbilldog.com/blog Dennis at MedicalBillDog

      Okay, Mike, you got me there. I know, the samples come with a cost. This is especially true if the drug works, the patient will need the drug long-term, and the drug has no generic equivalent.

      I have found, however, that the “free” samples can provide long-term benefit in two ways. First, if the sample works, I might be able to find a cheaper generic. That way, I get to test drive the Cadillac even if I end up driving the K-car. Second, in some cases, I’ve had doctors feed some needs for years with samples. In over five years, for example, I never once had to pay for an inhaler. I didn’t always get the same brand, but all of them worked.

  • Taylor

    This is ridiculous. I agree with other comments–how could my doctor know what I am going to pay?! Sure they might know I have X insurance, but they don’t know my copay, coinsurance, deductible, cost for brand name script vs. generic. It is my responsibility to know this. If I decide it’s too expensive then I’ll ask about an alternative script. Also, when, and if my doctor recommends a test, xray or whatever I do it because I think they have my best interest in mind and there is a good reason why they’re asking me to get it.

    • http://www.medicalbilldog.com/blog Dennis at MedicalBillDog

      No no no. Damn it, Taylor, did you even read my article? Or did you jump straight to the comments. I said, “Doctors are learning that they have to know the cost of the procedures and drugs they order, and understand the impact of those costs on their patients.” I said “cost-aware.” I never once said anything about knowing the ins and outs of every insurance copay, coinsurance, and deductible. Yes, I do think your doctor should know the difference between the cost of the more expensive drugs (anything over $100/month is decidedly expensive) and their generic counterparts, if any. In most cases, I think it’s either financially insensitive or just flat out asinine to hand over a scrip for an expensive drug if you know a less-expensive generic is available. I’m not trying to absolve the patients of any responsibility to follow up on costs. I just don’t think it’s right for doctors to hit us with over-priced drugs and procedures with no warning–especially when less-expensive alternatives are available.

  • JPB

    This post opens an interesting question. If a doctor orders various medical services/products without knowing the cost, are they showing disregard for their patient’s financial health? I once had a surgeon tell me that he didn’t know what his fee would be! He followed up with,”Don’t you have insurance?”
    Until physicians understand all the implications of their orders, I don’t think we will begin to get any control of the cost debacle in medical care!

  • imdoc

    Dennis, here is a business challenge for you: Since there is clearly a great need for patients to know what things will cost and physicians are not providing this needed service, you should develop a website that allows people to enter in data and get an accurate output of what the out of pocket cost will be. I am sure people would gladly pay and you would do well with this financially. By the way, good luck finding out what most insurance companies will actually pay and whether or not one has met deductibles, co-pays, co-insurance, etc and whether or not there is in-network discounts or uncovered services. You will also need to actually get a price list of all services from every hospital and imaging center then be aware of how to navigate coordination of benefits and eligibility. Seems simple enough.

    • http://www.medicalbilldog.com/blog Dennis at MedicalBillDog

      Yeah. Nothing to it.

      Every patient who will pay for that service raise your hand.

      Of course, I’m not asking any such nonsense of doctors. All of my doctors tell me when they’re prescribing an expensive drug or ordering an expensive procedure. If they don’t, I find a new doctor. None of them provide all the details of the final costs with insurance figured in. Nor did I suggest any such thing. That’s a straw man.

      • Vox Rusticus

        So you would like me to pay for that service? No thanks. You can go to another doctor if you think that will do you any good. I don’t see what good your advice will do any patient except to feed an unfounded entitlement mindset.
        If a patient wants to know what a specific test costs, they can call the radiology center or lab and ask. What is stopping them?

        • r watkins

          Exactly. If you want to know how much something costs, ask the person who sells it.

  • http://www.vitalityhealthinsurance.com Ray Carlson

    Wow I can see this is a really sensitive subject – on both sides – so please know I’m approaching this as Switzerland (!). I’ve had the opportunity to post an article here previously at KevinMD.com on the consumer advantages of the HSA-compatible health plan. One of the primary drivers behind the advent of the HSA was to prompt consumers to be more proactive about how they spend their health care dollars and thus be more a part of the process of helping to hold the line on medical costs. One of the commenters here proposed “a website that allows people to enter in data and get an accurate output of what the out of pocket cost will be” – actually this already exists and I’ve discussed it in several articles at my own Vitality website blog: It is part of the ‘value-added’ services provided by carriers for their members to help them get a read on what certain medical procedures will cost. The tool is free and offered as a value added plan member benefit.

    Do I expect my internist to know how the tool works or direct me to it? No. Doctors are busy, busy people and I respect that – but I do think it makes sense to ask that Doctor’s office personnel be proactive and help guide patients towards these cost tools: “I see the doctor wants you to get ‘procedure or text X’: You have ‘Company X’ insurance – remember that your member benefits include a cost estimator/comparison tool that you can find at their website and you should try to make use of it as it will help you manage your health care costs…”

    When a doctor is ‘in-network’, their business is a strategic partner to the business of the insurance company and the process of delivering affordable health care in this country – I think a gentle reminder and guidance to a patient from office staff that these cost tools do exist and can help the patient and our medical system itself are a ‘win’ all the way around. It can’t hurt to keep reminding consumers that these tools are there for their use and can be hugely helpful to them and the system we’re all a part of. Think of it as a nice “buckle up” reminder on one of your community roads…

  • Dennis at MedicalBillDog

    I’m not angry at doctors. I like my doctors, but I found the ones who demonstrate a degree of financial sensitivity. I find it ironic that you, while demonstrating in your comments that you also show such sensitivity (I never wanted mire than the “rough estimate” you suggest). I also find it ironic that some will berrate me for my laziness with one breath and insist that the costs are confidential with the next.

    Don’t worry, Gentle Reader, the tale of confidential costs was mere hoakum.

    As the article I originally cited poses, I disagree that this has nothing to do with bedside manner. Insensitivity to patient costs is insensitivity to the patient. I think any real patient advocate would understand that.

    • Vox Rusticus

      I can’t tell to whom you made the comment in your first paragraph, but I don’t see where anyone has written anything as you allude to in the final sentence of that paragraph.

      I wrote that I don’t have pricing information for studies performed by outside centers, and those prices are not shared with me. I also wrote that the negotiated contract pricing between private insurance carriers and individual providers are usually considered confidential business information and are not shared publicly. Now you may think that is “hoakum” but it is true. I don’t get to know what Aetna will pay Labcorp for any particular test. Except for Medicare, whose pricing is public, that is true for all private carriers. I am surprised that you claim to be some kind of patient “advisor” yet you are not aware of that fairly elementary fact in how pricing information is developed.

      Why you think I as a private physician should somehow have that confidential information for a transaction that does not involve me is something that you have not explained, except that you assert that I should. How? Why?

      If a patient wants to comparison shop between labs or radiology centers, or even doctors, they can pick up the phone and call and ask. If they have an insurance carrier that requires a certain lab for in-network benefits, most already know which lab they must use. My knowing pricing isn’t going to make one bit of difference in their choice.

      And Dennis, this has nothing to do with bedside manner, no matter how much you wish to believe that it does.

  • http://www.medicalbilldog.com/blog Dennis at MedicalBilDog

    Well, Vox, if that’s what you meant, you were not clear. You said the radiology centers “aren’t sharing their pricing or contracts rates” with you and that those are “confidential.” Now, I can agree with half of that: the contract rates, but I was never discussing the contract rates. I meant, as I keep saying, the bare unmitigated costs. Also, you included pricing in that statement, which is the hoakum I referee to.

    Finally, you go right on believing that financial insensitivity is nothing to do with bedside manner, and I’ll go right on telling my clients to shop around for more caring physicians.

  • Dennis at MedicalBillDog

    Oops. iPhone typo. In that last “referee” should have been “refered.”

  • imdoc

    So, regarding “bare unmitigated costs”, do you mean book prices of tests or medicine? Suppose a patient needs an expensive test such as an MRI and the hospital wants to charge $3000. As a “sensitive” physician, the suggestion is that I should quote this price. The implication here is that the patient will make a decision based on that information, correct? Now, considering that the doctor has no idea what the patient will ultimately pay, the quoted price is not meaningful. Arguably if the patient comes to harm from refusing the test, it is on the strength of the information provided. That is why I choose to not guess at things, be it clinical or expense issues. To do otherwise is not responsible.

  • http://www.medsavingsblog.wordpress.com Stephen Meyers, MD

    Overall, I agree with the general conclusion of your article, which is to recommend that patients inquire about the potential cost of the recommended care plan.

    Previous posts are correct in that there are too many variables for a medical provider to be able to quote an exact cost in most situations. However, a ballpark worst-case estimate can usually be offered.

    The simple (and sad) truth is that medical providers barely have enough time to render the care itself. Cost discussions often don’t occur unless prompted by the patient.

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