I’m part of a physician Facebook group — a large group of tens of thousands of physicians that many Doximity readers are likely members of as well. Several months ago, a physician posted about a patient who had contacted her, frustrated about the cost of services rendered at a previous visit. It’s no longer abnormal with our high deductible plans and treat-first-bill-later health care system that unpleasant and sometimes shocking bills occur, but what intrigued me about this post was the response of most group members. Physicians’ comments generally revealed an impulse to completely disconnect themselves from the patient’s cost and bill. Suggestions ranged from showing empathy but effectively throwing one’s hands up in the air to adamantly encouraging the poster not to engage in this type of conversation, with the justification that this isn’t part of their job.
None of these suggestions are "wrong," per se; there is rarely one right way to deal with a personal or professional conflict. There is certainly wisdom in the comments from physicians practicing much longer than myself about the benefits of distancing yourself from the "money talk" — such as building trust with the patient, reassuring them that you are making decisions in their best interest and not with a bottom line in mind, following care guidelines independent of cost, and treating all patients equally regardless of their insurance status or ability to pay. But I also wonder whether playing hot potato with the patient’s concerns dismisses the clinician’s role in health care expenditure and the effects our decisions, and our willingness to talk about their consequences, have on our patients.
Though we clinicians make hundreds if not thousands of weekly decisions that culminate in this country’s total health care spending and have real effects on patient bills, only a small minority of us are actually involved in policy making, insurance plan design, or billing and coding regulations. This begs the question: What are our roles as clinicians in talking about the cost of care with our patients?
Over time, the U.S. medical culture has evolved from one of prescriptive paternalism to shared decision-making with our patients. As a modern clinician, I am comfortable saying the words “I don’t know” to patients when they ask questions about their health outside my scope of practice, or when they seek information on an off-label treatment I haven’t come across. In fact, I have found that revealing a knowledge deficit and being willing to learn builds trust. But when I suggest a course of action to a patient and they ask me how much it costs, admitting “I don’t know … I don’t even have a ballpark or a realistic way to find out,” makes me feel true discomfort. I hate telling patients that it depends; the cost could be nothing or it could be several thousand dollars. I feel as though I’m not providing enough information for us to decide together on the right plan.
With ever-growing health care spending and headlines about burgeoning costs, it’s easy to forget that "spending" and "costs" translate into very real bills for our patients. Though my job is primarily outpatient now, I remember thinking regularly on the wards, Is it ethical to provide care that we can’t even ballpark a price for? Before each episode of care (both outpatient and inpatient), most patients are asked to sign a financial agreement that effectively states they are willing to accept all subsequent costs, which as we now know can be negligible — or crippling. Knowing that many of our patients have signed these documents as a prerequisite to getting care, my personal onus of responsibility to acknowledge the cost of the options presented has certainly changed, and it never sits well with me when I don’t have the tools to do so.
I would love to live in a world where no one has to ration their care based on cost, but because our system places the burden of insurance and payment on the patient, the patient should be able to make informed choices. In the U.K., the National Health Service takes cost into account when deciding on options for their citizens; I believe our patients, who bear the ultimate responsibility for the cost of their care, should be afforded the same opportunity. For most people, receiving health care can cost a substantial amount of money; being unwilling to acknowledge cost can cause our patients harm. I’ve had the displeasure of seeing family members on the other side of an enormous bill go through the yearlong journey of fighting it — a process which has seemed to have more of an effect (albeit a negative one) on their health and well-being than the actual care they received.
I’ve found that when patients are able to make those value decisions for themselves, sometimes they surprise me. I see patients decline to pick up medication at the pharmacy because the cost was too high (whether it was truly exorbitant or I felt they would find it reasonable). Do I agree with their decisions? Not always, but by avoiding the discussion of cost prior to rendering services, we aren’t allowing our patients the agency to make their own value judgments. In these scenarios, are we truly engaging in shared decision-making? Perhaps one medication is too expensive, but they’d be willing to take another (even if it is second line or comes with a different risk profile) that is in line with their budget. Perhaps a certain test is recommended, but not urgent, and they would rather wait until the end of the year to see if their deductible is met. I don’t think all of these conversations should happen in the exam room, but we need more resources in and around the care setting to help patients navigate the current landscape instead of fighting it after the fact when the financial damage has already been done.
Given both the unpredictable nature of real-time care and the complexity of today’s health insurance landscape, it is currently nearly impossible to state with certainty what an individual will be responsible for after their episode of care, save for cash-pay procedures and practices. That said, there are ways to demystify the cost of care that don’t place the burden exclusively on physicians and patients. Offices and health care systems could educate patients prior to their appointment on how to get information about their insurance plan and look up their deductible and year-to-date health care spending. Software plugins could estimate prescription costs prior to sending them to the pharmacy.
Some of the issues related to cost uncertainty will hopefully start to improve with the No Surprises Act, which aims to protect insured individuals from costs related to unknowingly receiving out-of-network services. There is also new legislation requiring hospitals, and soon insurance companies, to publish their price lists, and tools are being developed to estimate the cost of a particular procedure based on an average of billed costs. I believe that we can’t keep ignoring the elephant in the room: cost affects our patients and their health care decisions. A willingness to have tough conversations about the cost of care will ultimately lead to better patient outcomes and more, much-needed solutions.
How do you approach cost with your patients? Do you see it as a clinician's responsibility to engage in those conversations? Share your thoughts and experiences in the comments below.
Rebecca Yanovsky Dufner, MD, MBA is a resident physician training in dermatology in Boston, MA. She graduated from Stanford University, Tufts University School of Medicine, and the Heller School for Social Policy and Management. In addition to her passion for dermatology, she has led cross-functional teams in health care and in tech, and is interested in health outcomes, access, and delivery on the patient and population level. Rebecca is a 2021–2022 Doximity Op-Med Fellow.
Illustration by April Brust