Doctors must discuss the cost of care with their patients

I have been writing a bit lately on the need for health care providers to talk with their patients about health care costs, if for no other reason than to enable patients to determine whether they can afford to pay for the healthcare that their doctors are recommending them to receive.  I have been criticized for this position, on the grounds that I am rationing care from people with less money and connections than I have, a criticism that I have explained as being misguided.

But I have faced another more reasonable criticism too, one I want to write about today.  I have been reminded that doctors and other healthcare providers cannot easily discuss healthcare costs with patients because those costs are often unknown. Lisa Rosenbaum made this point in an excellent New Yorker essay:

The first problem with financial disclosure from doctor to patient is a practical one. Doctors rarely know how much their patients actually pay. Patients are covered by a variety of insurers, all of whom offer several plans, for which any individual patient has a different copayment and deductible, which he may or may not have met.

In this post, I will lay out a fuller version of this criticism and then explain why I still think doctors need to hold these conversations, and also why I think these conversations will become much more common in the near future.

This criticism was nicely phrased by Julian Fisher, a neurologist in Boston who wrote a letter to the New York Times.  Fisher wrote: “It is doubtful that any physician in the United States knows precisely what a given procedure or treatment costs, how much an insurer might pay with negotiated rates, and how much the patient will ultimately be responsible for.”

I completely agree with Fisher on this point.  Physicians cannot know the precise and specific costs.  Indeed in our New England Journal article, Amy Abernathy, Yousuf Zafar and I acknowledge this fact: “The current reality is that it is very difficult, and often impossible, for the clinicians to know the actual out-of-pocket costs for each patient, since costs vary by intervention, insurer, location of care, choice of pharmacy or radiology service, and so on.”  But we also continue to add “nonetheless, some general information is known, and solutions that provide patient level details are in development.”

I want to elaborate on that point right now.

Even when costs are difficult to determine precisely, physicians still often have a good sense of which interventions are relatively expensive and which are probably pretty cheap.  We know that generic drugs are cheaper than trade brands.  We know that PET scans are more expensive than CT’s.  We surely realize that colonoscopies are more expensive than fecal occult blood tests.

Now of course, physicians don’t know how much a specific patient will pay out of pocket for any of these services.  But that is OK because financial staff in our medical clinics will often be able estimate these costs for our patients or direct patients to someone who does (for instance, the patient’s insurance company).  In fact, it is relatively straightforward to imagine a shift in our clinical paradigm, where physicians alter the flow of patients in their clinic so that those who are financially distressed by the cost of medical care, after first meeting with their physicians, walk down the hall and talk to one of the billing experts in the clinic.  The billing expert can help the patient determine the cost of given healthcare services for the patient, and the patient can then return to the physician for a final check-in, to decide whether to receive specific services or, instead, to look for less expensive ones.  A meeting with this kind of a financial expert will help patients gain a fuller sense of the costs and benefits of their health care alternatives.

Perhaps this paradigm shift sounds unrealistic to many busy clinicians.  But I want to remind them that we already practice medicine much this way when patients face serious medical choices.  A woman with breast cancer, for example, might hold an initial meeting with a surgical oncologist, then meet with a radiation oncologist followed by a medical oncologist, before potentially looping back to the surgical oncologist and deciding upon a final treatment. Visits with physicians can even be followed up by visits with allied professionals.  When my wife had breast cancer and met with a plastic surgeon to talk about reconstruction alternatives, that meeting was followed up by a visit with a nurse practitioner who more fully explained the options to us.  We were then able to pose any final questions to the surgeon.

Medical practice is increasingly becoming a team sport.  Good clinicians recognize that to help patients understand their medical care, it is useful to partner with allied health professionals.   To that list of health professionals, we might need to start adding people who can find out how much healthcare is costing specific patients, and whether those costs are becoming a burden.

Sound unrealistic?  Keep in mind that cost conversations are going to get increasingly frequent soon.  A number of companies have formed in recent years to help patients discover the cost of proposed medical interventions.  One such company, Pricing Healthcare, is collecting information on medical bills from patients to develop a database that will help future patients estimate their healthcare costs.

Another company, ClearHealth.com, provides easy to glean information on the costs that self-pay patients will need to fork over to receive common healthcare services.  Women in New York City looking for a mammogram can discover, for example, that All County Radiology will charge them $50 for a mammogram, while Mount Sinai will charge $607.

Yet another company, Castlight Health, offers people information on how much they will pay out of pocket, given their specific health insurance plan and their year-to-date healthcare spending (thereby accounting for whether the person in question has met her annual deductible).  Castlight is selling this service primarily to health plans and employers, not individuals, but as more employers pay for their product, more individuals will have ready access to that information.  I have spoken with people at Aetna who are developing a similar product of their own.

Like it or not, physicians cannot expect to practice medicine without discussing the cost of care with their patients.  This is going to be difficult for a while.  But I expect these cost conversations will get easier over time, as physicians gain experience holding such conversations and as they, and their administrative staff, become more familiar with how much various healthcare services cost.

Rather than resist this inevitable trend, physicians should embrace the opportunity to help their patients better understand the full ramifications of their healthcare alternatives.

Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel.  He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices TogetherThis article originally appeared in Forbes.

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