The cost of avoiding cost: a medical student’s perspective

My first meeting with a therapist was a success: she specialized in type-A personalities, was transparent about her eclectic approach, and her office – on the bottom floor of a converted San Francisco townhouse – felt somewhere still and safe, a purple-carpeted hideaway in the belly of the Earth.

On the train out of the city, I watched my reflection melt in and out of the glass: I was a person about to become a different person, and I was hopeful. Dr. Taylor had made no grandiose promises of overnight recovery, and I had no such delusions. I was committed to working for change; it was the type of thing I was good at.

The call came on my walk home; it was a number from the city, a pretty voice on the other end.

“Hi Miss. Patel, I hope you enjoyed your consultation today. I was calling to ask if you’d be using insurance to finance future visits, or paying out-of-pocket.”

I paused outside a sushi restaurant, digging my ballet flat into the asphalt and pretending to browse their takeaway menu. “Um no, I won’t be using insurance. How much do the visits cost?”

The pretty voice exhaled, a Billie Holiday record spinning behind her. “Dr. Taylor charges $425 for the hour, and $275 for the half-hour.”

I slipped the takeaway menu into my pocket and watched my reflection, distorted by the sushi restaurant’s oily plexiglass, pull its teeth into a broad smile. “Lovely, I’ll call in a few days to set up my next appointment!” Once home, I pulled my cellphone out of my coat and blocked the clinic’s number, ensuring that they could never follow-up with me again.

That call left me deeply embarrassed. I’d researched the costs of therapy beforehand, scoured Dr. Taylor’s website for a menu of prices, and after being unable to find one, had assumed they’d be somewhere on par with industry standards. How wrong I had been.

But worse than the embarrassment were the side-effects of delaying treatment: it had taken me six months to set up that 30-minute consultation, and the fear of a repeat-experience pushed me to wait another six before seeking help.

Now, as a medical student, I often feel like the pretty voice on the other end of the phone, soft jazz playing behind me while my patients struggle to pay their bills.

For an industry that prides itself on open communication, health care is surprisingly hush-hush about costs. Prices are never listed: $75 for therapy, $200 for back-to-school vaccines, $2600 for the MRI. In many ways, providers are not to blame. The cost of treatment can vary dramatically based on a patient’s insurance-status, comorbidities, and preferred provider.

Beyond that, it’s difficult to predict what a patient’s health care journey might look like at its outset. Take type II diabetes as an example: the average diabetic incurs $16,750 in medical expenses each year, but some patients are well-managed on just a gym membership and metformin. The popular argument against price transparency has been variants of “health care providers aren’t Nostradamus; how can they predict cost when they don’t have all the information?”

The trouble with this argument is that it implies that health care providers only make decisions when they have all the information. The practice of bed-rationing in the ER rapidly disproves such conceptions: patients with ear infections are sent home with a prescription. Their providers make the good-faith prediction that their illness is not a symptom of a more insidious diagnoses. Such predictions are important – without them, the ER line would loop around the block, delaying timely medical care.

If health care providers are comfortable making prognostic predictions, why are they so uncomfortable predicting cost? The problem boils down to a lack of training: during my four years in medical school, I will take a dozen classes in pathophysiology, genomics, and radiology. I will take just one course in health policy, which will dedicate a single lecture to estimating costs. Given this lack of training, it’s easy to see how finances fall to the wayside.

The crusade against costs also has a cultural component. After Congress signed the Emergency Medical and Treatment Labor Act (EMTLA) into law, forbidding denial of care based on the ability to pay, cost conversations became taboo. Medical educators taught students to treat a disease the most effective rather than the most cost-effective way. The trouble is, compounding costs seriously impair a patient’s ability to manage current therapies and seek future treatment. It’s no wonder then that patients left to “sort out the money piece” stop taking their medications, don’t return our calls, and let their conditions progress unmanaged.

Traditionally, providers have argued that preemptive cost conversations might discourage patients from seeking help. However, delaying these conversations can actually delay care: had I known that a single therapy session would cost $425, I would have simply booked an appointment elsewhere – at a price that allowed me to seek help and pay my rent. Instead, the lack of price transparency drove me to delay treatment for another six months, during which my mental health worsened.

Of course, the conversation around costs is far more nuanced – both ethically and socially – than I can do justice to here. I will conclude that while cost control shouldn’t be the center of medical education, it should certainly be a part of it. If we don’t learn how to explain pricing to our patients, we risk presenting unrealistic therapy options. This burdens our patients with debt and guilt – a price they shouldn’t have to pay for health care.

Palak Patel is a medical student.

Image credit: Shutterstock.com

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