Whether or not patients share cost concerns with physicians, financial issues are a growing part of healthcare decision-making.
Until recently, physicians have been wary about these discussions.
But the landscape has shifted in the last decade.
In 2013, The New England Journal of Medicine published a physician-authored essay that called costs a “side effect” and urged physicians to “disclose the financial consequences of treatment alternatives just as they inform patients about treatments’ side effects.”
As a result, physicians now weave cost into their discussions more frequently, even though that can be uncomfortable at times.
The problem is that not all physicians are engaging their patients on cost during their discussions.
While most of patients feel it is important to discuss the costs of their care with their physician.
The place to start when talking about healthcare cost with patients is to consider the discussion fairly with every patient.
Physicians should not make assumptions about which patients may want to have financial discussions.
It’s not just about finding patients who can’t afford to pay their co-pay or for prescribed medications.
It’s also for people who want to plan for what’s coming down the road.
Barriers to discussing cost
There are a variety of reasons why doctors are reluctant to discuss care costs with their patents.
Most healthcare services don’t come with a set menu of prices.
Moreover, the patient’s portion can depend on their insurance plan, deductible and billing code.
So, rather than seeking the exact cost of each treatment option, find out the relative cost of the most-frequently prescribed medications or services, and places with potentially lower pricing.
While a doctor doesn’t always know which lab charges preferred rates for which insurance plan, patients sometimes know which labs or imaging centers their insurance company prefers.
Or he’ll tell them that there may be a cost for the service and suggest that the patient finds out what lab the insurance company recommends.
He may ask the patient to find out if their insurer will cover a blood test as preventive lab, and if not, she sometimes can order it using a different code, like noting a strong family history of the disease.
Doctors think cost discussions with patients are more time-consuming than they are, since data show that the amount of time they actually take is quite short.
Moreover, cost conversations can potentially save time in the long run, as the doctor may be able to avoid subsequent calls from the pharmacy for an alternative prescription, or not have to identify potential adherence issues during future visits.
Lack of ready solutions
Physicians often experience stress when asking patients about cost, because they’re not always aware of resources to help them.
Primary care physicians have more alternatives than oncologists, in that there are often generic medications, which might be less expensive.
While some medical treatments and diagnostic tests are unavoidable, others can be spread out to help with budgeting.
This may give the patients the option to choose between different treatment pathways, or delay a test or procedure the patient ultimately decides is not worth the cost.
Doctors sometimes delay ordering tests for patients who are clinically stable, so they won’t have to pay for tests they might not need.
While they are talking with patients about the costs of outside treatment, they feel uncomfortable bringing up the cost of their own visits, especially follow-ups.
They want them to come back, to see how they’re doing, or if that’s difficult, to email them.
Quality of healthcare
Even when doctors bring up cost issues, patients may be reluctant to discuss them out of concern that they won’t be offered all care options in the future, or that they’ll receive lower quality care.
So after determining that finances are an issue, doctors reassure patients that they’ll make all medical decisions together and that the patient will be presented with all options, regardless of cost.
For the insurance-covered wellness visit, doctors can’t talk about anything but what’s covered in the annual visit, by strict guidelines.
If they talk about blood pressure that is high and change the prescription, as a result, they have to charge for it.
How to talk about cost
It’s important for the physician to bring up cost of healthcare, because patients don’t always know that they can ask about it, or hesitate to do so.
It’s clearly something that patients worry about - the financial impact of medical care puts stress on people.
Some patients feel ashamed and don’t want to raise the issue.
To create a welcoming environment, physicians can use language like “a lot of my patients have trouble affording medications.
Has that been an issue for you?"
People don’t want assumptions made about their financial situation, so physicians should ask all patients.
The universal approach makes people feel more comfortable.
Sometimes, we consider cost as a side effect, patients should expect.
We’re careful to inform our patients about the side effects they might experience from treatment, and cost is one of them.
Even if we can’t give an exact amount, we should inform patients that they will face expenses not covered by insurance, as a result of the treatment we are prescribing.
Some doctors prefer to talk about affordability rather than cost.
If we tell the patient, we want to make sure they can afford the treatment that helps align doctor's interest with theirs.
We’ll say, “I want to make sure you get the best treatment possible and that you can afford that treatment.
Let me know if you have problems paying for your care.”
The physician is often the best person to initiate the cost discussion, because he is responsible for the treatment plan.
But other team members can sometimes help as well.
If the office uses a nurse or medical assistant for medication reconciliation, that person can include a question about the affordability of medications during the intake.
We suggest meeting with practice staff to find out what patient questions they’re getting about cost and who gets which questions.
They can share resources, such as which facilities offer less expensive imaging, procedures or medical supplies.
Cost of healthcare tools
Care costs can also include transportation, child care and lost wages.
While a solution may not exist for every cost issue a patient faces, physicians are better able to help their patients if they know the patient’s challenges.
“Not talking about it will not work.”