Talking treatment costs: Navigating financial discussions with patients
The growth of high-deductible health plans has led many patients to absorb more of the financial burden for their medical care, leaving physicians in the difficult position of engaging with patients on financial matters
When David Margolius, MD, realizes that a patient is fretting about a medication’s price tag, he’ll pick up the phone, likely with the patient right there. As he makes the gauntlet of calls to several pharmacies, asking them to price the drug based on insurance coverage, he’ll proceed with his exam of the patient.
“Because I know I’m going to be on hold half the time,” says Margolius, an internist at the University of California, San Francisco, “I say [to the patient], `Let’s talk to the pharmacy together.’ I feel like it helps to builds the team spirit with me. That we’re going to figure this out together.”
Footing the medical bill, a perennial challenge for those lacking insurance, is increasingly becoming a source of stress for insured patients, as high-deductible plans proliferate. By 2014, 20% of Americans with employer-provided insurance were enrolled in these plans compared with 8% just five years earlier, according to an annual survey from the Kaiser Family Foundation and the Health Research & Educational Trust. Hefty deductibles also are frequently part of plans sold through the Affordable Care Act exchanges.
By late 2014, one-third of Americans reported that their out-of-pocket costs had increased “a lot” in the “past few years,” according to a CBS/New York Times poll of 1,006 adults. The vast majority of those surveyed, 80%, said they would prefer for their doctor to discuss the cost of a recommended treatment in advance.
But how does a doctor raise or address the sticky question of money, amid a time-pressed visit. Is that part of their role? Are there ways to handle the money piece of the equation so it doesn’t significantly extend the visit, or erode the doctor-patient relationship in some way? Doctors such as Margolius believe that cost sensitivity can be incorporated into a routine visit, and that ignoring the issue only places the patient in potential peril.
Margolius describes the example of a patient with asthma he treated during his residency who was struggling with a surprising degree of wheezing and shortness of breath. After some questioning, Margolius learned that she lacked prescription coverage, and so was spreading out the use of her inhaler, which cost roughly $150 for a month’s supply. Her clinically faulty rationalization, as he recalls it: “`If I could stretch out this inhaler over three months instead of buying a new one every one month, then I’ll be good.’”
Yousuf Zafar, MD, MHS, an associate professor of medical oncology at Duke Cancer Institute, says that his wake-up call involved a patient who refused to again take a particular chemotherapy drug. It turned out that the patient’s insurance didn’t include prescription drugs, so the first six weeks of the regimen had run up the patient a bill of roughly $2,000, he says.
In that case, there was an equally effective intravenous drug alternative that would have been covered under the patient’s medical benefit, Zafar says. “I could have prevented thousands of dollars in medical debt by simply asking him, `Do you have prescription drug coverage?’” he says.
Now Zafar asks more routinely about cost pressures, and believes other physicians are starting too as well. “There is so much evidence that patients are non-adherent because of costs,” he says. “We’re not doing patients any favors by prescribing them what we think is the best care possible, only to find out that they can’t afford it.”