Should a patient’s financial concerns influence physician decisions?

I treat uninsured patients and insured folks who face high deductibles who are under financial strain because of the sagging economy and other personal pressures. These folks need care that may be unaffordable. Medical diagnostic testing is expensive. Even routine laboratory testing can be very costly as those without insurance may be forced to pay the ‘retail cost’, which is quite different from insurance company discounted pricing.

This absurdity is often seen in the emergency room where an uninsured patient can be billed thousands of dollars compared to an insured person who has received identical medical care whose insurance company will pay a fraction of this amount. Crazy.

Because I am a human being, I try to be sensitive to my patients’ financial concerns. Does the uninsured patient before me really need a CT scan or a colonoscopy? Couldn’t we just watch and wait for a week or two and spare him from the expense?

Consider this scenario.

A 50-year-old uninsured patient comes to see me with fever and right -sided lower abdominal pain for 3 days. The pain is nearly constant and has awakened him from sleep. He had a night sweat during the night prior to my seeing him. In the office, he looks uncomfortable and had a temperature of 100 degrees Fahrenheit. His abdomen was moderately tender when I palpated him. I am aware that he cannot afford medical care.

Which of the following responses do readers endorse?

“While normally I would advise a CT scan, I am going to prescribe antibiotics instead. Call me 2 days from now to let me know how you are doing.”

“Let’s do an ultrasound (US) test to see if you have appendicitis. While a CT scan gives much more information, the US is much cheaper.”

“You probably have a ‘bug’ that has been going around. I’ve seen a lot of it lately. Just take fluids and rest. Use Tylenol for fever. Give me a call in a few days. If it gets worse, you had better head to the emergency room (ER) to make sure you don’t have a burst appendix.”

“I advise a CT scan as you may have any of a number of conditions that the scan may identify. I know money is very tight for you, but I can’t back off this.”

“Go to the emergency room. I know that you are still paying off the $1,900 bill from your ER visit 2 years ago. This visit will cost even more, but I can’t put a price on your health.”

I’m interested in what readers think here. Do you favor any of the above responses or, perhaps, you can suggest one that I’ve omitted. How should doctors’ advice be modified in response to patients’ financial conditions?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • David Gelber MD

    I worry about treating patients differently because they don’t have insurance. If a patient has abdominal pain and you would normally evaluate them with a CT Scan, but don’t recommend it because they don;t have insurance and miss something major that leaves you with some liability. I will usually recommend what I think is appropriate. If the patient declines because of financial reasons I document that and will offer alternatives.
    Years ago a Urologist was fretting over placing a stent in a sick, uninsured patient. My advice was to not alter recommendations because of insurance status. Especially for patients already in the hospital, do what is right. Our job as physicians is to treat our patients to the best of our ability. There is no way we can solve the social problems that exist in health care today.

    • MKirschMD

      Agree entirely, David.

    • mmer

      //There is no way we can solve the social problems that exist in health care today//

      Should the effort be put forth? Who’s going to do it? Providers, being in the position that they are (community role, high status, authoritative) seem to be in posession of many factors, which, if galvanized, could be politically forceful. There is an issue of time commitment though ..

      Politicians are certainly are not going to prioritize patient interests when crafting legislation.

  • PollyPocket

    Patients often don’t realize that if the phycisian recommends a CT there is a secret second, third, or even forth option.

    When I was told that my young, and neurologically intact, child may have a tumor vs migraine the recommendation was an MRI. But for a three year old, there are risks associated with sedation that are not fully understood. So we discussed other options, like expectant management. I am very happy that the physician was able to support my decision to postpone MRI, and letting me know that it was indeed an option, and not a particularly bad one helped me to make that choice.

    • Jason Simpson

      The problem is people like you will be very quick to sue the doctor in the unlikely event that your daughter actually DID have a tumor instead of just migraines.

      • PollyPocket

        That’s very presumptuous

  • drgz

    Being a corporation these days is risk free. It is designed that way so that everyone else that can’t handle it, takes on the risks themselves.

    They leave that burden to the doctor and mainly the pt. This is a wonderful example of how the insurance companies, hospitals,or even government, that can handle such risks or should be handling risks (after all that is what insurance is for) are no longer taking on risks. Much like banks these days.

    The fundamental problem that I think you and many of us are struggling with, is it can feel as if we should take on the risk or share the risk with the pt. If the CT is negative then you’ve wasted the pt’s resources and if you don’t and it becomes an emergency then you might be made to feel as if responsible in some way . Why is this the doctors problem? But in a way it is dumped in our laps since insurance companies don’t take on risks these days as exemplified by the fact that they deny many preexisting conditions.

    This is absurd to have to struggle with this sort of feeling of risk as a doctor. As much as I know this i also struggle with this at times. I would agree with the other post that if your pt needs a CT scan then he needs a CT scan period. It is not the doctors job to take on the risk of CT vs no CT.

    I know there are places that will negotiate fees for pts that pay cash. And of course academic institutions that will put a lien on your home for a CT.I will start with transparency since that seems to be an issue these days.

    My 91 yo father got a CT scan of abd and pelvis plus chest. He told me the cost was $13000. He is not senile.This was done at Stanford University. Here is the break down.

    CT scan chest with contrast $5309
    CT scan abd and pelvis $7711

    Medicare pays $752.98 and pt pays $192

    i would tell your pt to avoid getting his CT scan at Stanford.

    • Kristy Sokoloski

      It is understandable why the doctor would have recommended the CT Scan because the situation in front of the doctor calls for it. However, if that pt can’t afford the test even with insurance paying some of the cost they can’t afford it. So what are they to do? It’s even worse for those that don’t have health insurance because they can’t afford the kind of payments that are expected to get the bill paid. This is one reason why for those that have gone ahead and gotten the various tests done many times will often end up in bankruptcy to clear themselves of the burden. Because the burden of the payment is just too high.

      • drgh

        Agree Kristy. This is not something that can really be solved in a doctors office. I think it is wrong for either the doctor or patient to take on that kind of risk. I think we are saying sort of the same thing. It is unethical. That’s why i said “I know there are places that will negotiate fees for pts that pay cash. And of course academic institutions that will put a lien on your home for a CT.” It is unethical in this country to go bankrupt over a CT scan.

        • Kristy Sokoloski

          Right, I understand what you are saying about the places that will negotiate fees for pts that pay cash. However, if that pt is in a situation where their finances are so bad the amount that may be suggested to them to pay is still too high. It is interesting what you are saying that it is unethical in this country to go bankrupt over a CT Scan. I agree with this 100%. In my opinion it should also be unethical for people to go in to bankruptcy over medical care. However, so many in society that make use of the medical care system and as a result of it had major operations have had no choice but to go in to bankruptcy. Many of those major surgeries that need to get done cost hundreds and hundreds of thousands of dollars. Same thing for various other kinds of tests to diagnose problems such as heart problems. So with that said it makes me wonder what should be done because I also agree that it is wrong for either the doctor or the patient to take on that kind of risk.

          • drgh

            Could not agree more. Do you think the Obamacare will help in anyway? At least if you have insurance you won’t have to pay for a surgery. On the other hand how much is affordable for many don’t feel they can afford it even with full time jobs?

        • mmer

          In most advanced economies, medical bankruptcy is unheard of, in the US, it’s the number one cause of personal bankruptcy filings.

          This is something neither patients nor providers should be morally comfortable with (by and large, I don’t think they are). Broadly, the viewpoint that healthcare ought to be considered a commodity like a TV or a new car is poisonous.

          • drgh

            I did not know that. where did you hear that
            / i would have guessed foreclosures.

          • mmer

            2 studies to note, there is the Harvard study, “Medical Bankruptcy in the United States, 2007:Results of a National Study”

            “Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors,the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001″

          • drgh

            thanks mmer. That was quite eye opening. And disgusting i might add. If anyone thinks about it, it makes perfect sense. If you can’t work because of an illness, than you are disabled. If you have an expensive illness that requires costly intervention and you have no insurance of course this would lead to bankruptcy. If you have insurance, you can easily lose it because your employer could terminate you. then you go to 18 months of cobra and then you are pretty much destitute. I suppose then there is medicare. But it is so exhausting if you are very sick to sort through the mounds of BS and paper work to get help. It is quite humiliating i am sure. Especiaily if you have worked your whole life. It’s bad enough to get sick let alone be denied help.

    • buzzkillerjsmith

      13k for a CT should be criminal. It is gouging in the worst way.

  • http://barefootmeds.wordpress.com/ Barefootmeds

    In South Africa we won’t even do CT scans for suspected appendicitis precisely for this reason. We barely even do U/S for expected appendicitis. We diagnose clinically, which as far as I know EBM still endorses. So I’d want to know if this patient is guarding and if he’s had any bowel movements. Investigate for fecal impaction. And if we’re not sure, we usually use expectant management. Appendicitis pain will get worse.
    But what do you do when your patient needs surgery and can’t afford it? That I don’t know. We have free medical care at state hospitals for those who can’t afford it.

    • Alfredo Nieto

      Fortunately there’re a growing number of asociations that can provide some low cost or free services. Maybe find out about them in your area? so you have alternatives when a uninsured, low resource patient shows up?

      • http://barefootmeds.wordpress.com/ Barefootmeds

        For US doctors, definitely good to know. Not needed in South Africa due to free public healthcare.

  • DQUser

    If the doctors working in the front lines of the medical profession would take control of the AMA instead of it being the other way around and stop listening to the AMA’s propaganda, they could join the the rest of the industrialized democracies by having a similar single payer system. It would also do away with costs imposed on our system by the insurance companies.

    Having experienced both the European systems and the US one I can tell you categorically that theirs has better pt outcomes at less cost to the taxpayers and the pay and hours are better than the US’s.

  • Cyndee Malowitz

    I own a minor emergency clinic and most of my clients are uninsured or under insured, In these types of cases, I order the same tests I do for an insured patient. We have to meet the standard of care. Now, I might highlight what they really need.

    There are inexpensive discount labs available. I refer patients to a lab where a CBC cost $10 and CMP $20. They can get a chest x-ray for $30 (includes radiologist review) and sometimes work out payment plans for CTs, MRIs, etc.

    The problem is when there is a problem…who are you going to refer to? I don’t know any surgeons who operate for free.

  • drgh

    To be truthful, there are so many holes in the law, that even if you work, you can still struggle with being covered when you are sick. I was at Stanford medical records the other day chatting with an employee who was a contractor in medical records dept. Meaning she gets no medical insurance form Stanford. Here is this beautifully constructed building with a grand piano in its lobby. To be sure I thought I was i the finest of hotels walking into the lobby.
    This woman apparently got ill and ended up going overseas for help. She could not afford the “help” at Stanford.

  • buzzkillerjsmith

    I see these pts several times per year, rule out appy without financial resources.

    According to Ohmann criteria, the pt has at least 8 pts, probably more. I don’t see a white count and an assessment of urinary tract symptoms or a mention of any rebound tenderness. With a minimum of 8 pts and probably more, the standard of care around these parts would be imaging, best with CT as you all know. I would do a CBC and a UA to complete the lab workup and examine for rebound and check for a psoas and obturator. What the heck. Physical exam is cheap.

    As far as imaging, you could try an UTZ first, but if it was negative, an CT would be needed. Around here the UTZ is often negative even in acute appy. I generally go straight to CT.

    I tell the pt all these things, and if he or she refuse the test, I advise the appendicitis is serious and can be fatal. I advise about the risk of rupture, peritonitis and so on. If the pt still refuses, I recommend clinical re-evaluation in 8 hours. If the pt does have an appy, it might or might not be worse at that time. The pt has been ill for 3 days and fever is a very scary sign, so the pt might have already ruptured. This might not end well.

  • drll

    Or just do a self appendectomy. Get out a mirror and follow the Dr. Vladislav Rogozov method.
    So here are the facts: it happened during 6th Soviet Antarctic Expedition at Novolazarevskaya Station. The patient was the only physician on station, so the assistant was a mechanic. It was on April 30, 1961. The operation took 2 hours. He positioned himself so that he could see his own body using a mirror when doing the surgery – he made a 12 cm cut through which he found the appendix. After 5 days the doctor felt good, and after 7 days he removed the wires which had been used to sew up the body. His name: Leonid Rogozov.

  • Dr. Pamela Havekost

    I would keep him in hospital under close scrutiny, do an US and control the clinical condition after 2 hours, and later again – insofar watch the development of the condition – but it seems your system is the other way round than the German system? Around here private patients get the higher bills, normal insurances pay way less, and there are nearly no uninsured patients – but for them in most cases 1/3 of the bill of a normal private patient would be possible, I assume. Nevertheless our system is far from perfect, and doctors claim frequently against many constrictions.

  • anon3

    Why is he visiting a doctor if he can’t afford it? That’s extremely unfair and makes no sense. Your question also makes no sense. You should not change your clinical decision at any point unless you are working through a differential diagnosis. I am disturbed that it is possible to even ask this question. Presumably this is why the NHS is terrible and people get no tests and die, whereas people in the USA claim that they get too many unnecessary tests and those without insurance die.

    • heartdoc345

      To she’d light on the us system;

      All hospital emergency departments that take federal funds (ie bill Medicare for any services, which is virtually all US hospitals) are bound by EMTALA, the emergency medical treatment and active labor act – which basically states that you have to do a medical screening exam and “stabilize” any patient who presents to the ED, regardless of ability to pay. Likewise, specialists “on call” to the ED are similarly beholden, so if the ED deems a cath necessary for an acute MI, and the cardiologist on call refuses based solely on inability to pay, then the cardiologist is committing an EMTALA violation.

      Outside of the realm of the emergency department, physicians can choose to not see any uninsured patients. What’s tricky is that if a physician sees any Medicare or Medicaid patients, he or she is not allowed to provide care for free to anyone , since that would be considered Medicare fraud (unless the physician decides to provide free care to all Medicare patients).

      In our country, being underinsured may be a much worse problem than being uninsured. A totally uninsured patient will probably only receive care through the ER or maybe a free clinic, whereas a patient with a big co-pay will be able to be seen by all sorts of specialists and then have to deal with the bill later.

      My two cents on this issue is that it should be a fundamental responsibility of physicians to have a general idea how much things cost and take into consideration what resources a patient has. Certainly, if you’re ruling out an acute appendicitis, you should offer the full standard of care, giving the threat to life of a missed diagnosis. However, in many clinical scenarios there are acceptable alternatives that are much cheaper – for example twice daily metoprolol or carvedilol (both on the $4 list at Walmart) can treat hypertension as well as a more convenient once-daily metoprolol XL (likely well over $100 out of pocket for 30 days.). I would offer both to a patient and let them decide how best to use their resources, since there are other things they value that they may prefer to spend the other $96 on.

  • usvietnamvet

    Anon3 Pain is a great motivator. This is why people visit doctors even when they can’t afford it because they have no choice.

    That’s what the government and most Americans can’t understand.

    If you’re poor it’s usually not your fault. No one would choose to be poor. What’s worse is if you’re a working poor person because you don’t qualify for any government programs because you make too much but you don’t make enough to pay for extras and doctor visits are often extras.

    And if questions aren’t asked how are we supposed to move forward?

    It’s a shame that in this day and age that people die because there are no solutions. I remember in the 70′s when there were free clinics you could go to. Those don’t exist much anymore. It’s been proven that every dollar we save in preventative cares saves many more dollars.

    Doctors often have to make decisions I wouldn’t wish on King Solomon. Exactly who pays for the tests that are needed if the person is too poor? Most of the working poor can’t even afford to bury their dead. And it’s gotten worse as our politicians paid companies to outsource American jobs.

  • ninguem

    Mike, you’re in Cleveland, aren’t you?

    Where do you refer uninsured? Metro General?

    I would imagine the Cleveland Clinic is too busy with Middle Eastern despots to bother with ordinary hoi polloi.

  • anon3

    I understand desperation or just going because it’s logical.. but what happens when you let someone in who can’t pay? Surely that just puts the doctor in a horrible position? It’s not the doctors fault either that the patient can’t afford it and the doctor may want to treat you but can’t. I live in the UK so don’t understand how it works. I know however that I wouldn’t or couldn’t go to a paying doctor here, if I was ill. How could that work? Are you saying your doctors treat people then send them a bill to get them into debt? Or let sick people die? Turn them away? I mean if you can’t afford to pay for a $300 scan you definitely won’t be able to afford the treatment if you’re not given the all clear. Is the article more about how to keep costs down for people who are seeing doctors not able to afford it, and keeping their debt down vs giving the best care? I would assume that the correct answer is to always choose the same / best method and the debt is what it is. I can’t see how it would make any sense to be purposely negligent to someone who can’t even afford the test that won’t tell them anything anyway

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