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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