My workroom’s phone rang, and I cradled it between my neck and shoulder. We had just admitted a patient, and the call was from the nurse asking whether the labs I had ordered were truly necessary. The patient had already been worked up in our ED, but instinctively I’d reordered her basic labs when I became her doctor. I was only on day six of residency, and the “MD” emblazoned onto my white coat still didn’t fit right. The medications I’d prescribed and orders I’d placed had all been done with a sense of apprehension; the last error I wanted to make was hurting a patient by doing too little. I pulled up the patient’s chart and saw that her basic chemistries and blood counts had been drawn only a couple hours ago. Still, I wanted more data. I called the nurse back and begrudgingly said, “Yes, please draw the labs.”
The new labs didn’t change my clinical management. They were essentially unchanged, and I didn’t have much reason to think they would change. The next morning on rounds, my attending was happy with the patient’s clinical improvement, and we discharged her later that day. In many ways, her management by my team was largely uneventful; we identified the illness that brought her to the hospital and brought her back to health. Yet, I couldn’t quite nudge from my mind the call from the nurse.
I knew the subtext of the call. She wasn’t asking me about the labs, rather she was telling me she didn’t want to draw them. It’s a scenario we’ve probably all found ourselves in. Exhausted floor nurses, nearing the end of a grueling 12-hour shift, choosing to push back on orders they feel may be unnecessary. It was only through her pushback that I started thinking about the tests I had ordered.
The economic powers governing our health care system are as cryptic to me today as they were when I entered medical school. I may know enough buzzwords and statistics about our multi-payer model to pass as moderately well-informed at a dinner party, but truthfully, my understanding of our system is skin-deep. It almost seems intentionally designed to confuse those providing care within it. The numerous different insurance plans, the complexity of medical billing, the lack of price transparency, the significant variation in pricing for the same medications … the list goes on. Medical education may provide us with the knowledge of when certain tests and treatments are medically indicated, but it simply is unable to teach us the economic ramifications of our decisions.
In 2019, CMS enacted the Hospital Price Transparency Rule. This rule was made possible through the framework of the Affordable Care Act, and it allows patients to see how much basic medical services cost at various health care facilities. It is the passing of this law that allowed me to discover that my medical school’s teaching hospital charges self-pay patients $253 for a comprehensive medical panel. My current hospital charges self-pay patients nearly $100 less, and a hospital system in my hometown charges patients even less. When insurance is factored in, the cost to patients is further complicated by each insurance company’s negotiated rate and the patient’s copay and deductible. It is the same test with essentially the same basic cost to the health care system, and yet the cost to the patient is determined by a litany of different factors.
For physicians aiming to provide high-quality and affordable services to patients, the current system can be extremely frustrating. When I see clinic patients, I often find it hard to counsel them on the costs of diagnostic testing. Eventually, I discovered that there was a way to estimate costs to patients using my hospital’s EHR. It is a tedious process, one that required me to know their insurance and current deductible, and it could only provide me with rough estimates for services that I would provide. It is, however, at least something I can reach for.
Some could argue that my job as a physician is to merely assess the clinical utility of the health care services I provide, and that I shouldn’t be considering health care costs when working with patients. After all, I wasn’t trained in medical billing or in the business of medicine. Yet, the cost of every test and medication I order is shouldered by someone. I could indiscriminately order a variety of tests on many of my hospitalized patients and make a medically sound argument as to why they are necessary. Providing good health care, though, means methodically weighing the benefits of various tests and procedures.
Looking back, I probably didn’t need those labs.
Do you think about cost when you make care decisions? Share in the comments.
Lachlan is a new intern attending the USF Morsani College of Medicine. His interests include neurological research, medical humanities, and running. He has been a Doximity Op-Med Fellow since 2022.
Image by Fanatic Studio / Getty Images
