“Oh no, not again.”
My dismay had nothing to do with the medical condition I was experiencing at the moment. Sure, I felt like my health was crumbling apart. The echo of sirens was audible in the distance; the firefighters were speeding to answer my alarming call. Nevertheless, I was afraid not so much of my health outcome but of the inevitable bill I would receive after treatment. In it, I was guaranteed to find a crippling total that would include the transportation cost, ER accommodations, lab work, imaging, and clinician care time.
This was not my first rodeo as a patient. A few years back, when I was a medical student, I'd injured my foot during a soccer scrimmage after I made a wrong calculation of kicking the turf instead of the ball. In a matter of minutes, I saw my ankle inflate to the size of a baseball. My ED experience consisted of a visit from the doctor, three X-rays, and nausea medication. “There is not much we can do,” the doctor told me. “But good news, it looks stable. You can probably go home.” I was discharged that day with a pair of crutches and a prescription for mild pain. In the weeks following, I adapted my life to the new temporary scenario. All was going well. However, I soon found out that no hospital visit is exempt from financial ramifications. The amount owed for the ED visit was in the ballpark of $3,400. Fortunately, I had health insurance. If I didn’t have it, I didn’t know how I would get that kind of money.
Given that previous experience and its rippling effect on my budget, I decided not to risk getting a bill of that magnitude this time. So, while it was not the most sound decision, I asked the firefighters not to call an ambulance. “Just leave me by the gas station. I’ll manage this on my own,” I told them. My refusal of further medical attention was granted — perhaps because the firefighters, like me, were aware that an ambulance ride costs around $1,000, sometimes even with insurance assistance. As a resident physician, I didn't know how I would pay for this unexpected bill. It wasn’t like I could work extra hours to pay it off — I was already working so many.
Nevertheless, I was not off scot-free. A few weeks later, I received a bill from the city’s Fire and Rescue Department. The total cost for services? $399. I contacted my insurance, petitioning them to pay for it, but they declined my request, stating it was “out of network.” “We can offer a payment plan if you like,” the billing provider offered — hardly an ideal response.
These two experiences stuck with me long after I recovered from the second incident. As a physician, I’m not used to thinking about the cost of treatments — I just recommend the ones I see fit, not really considering how insurance companies and patients will handle it. It feels almost wrong to suggest that patients consider cost when their health is at stake — why should I prescribe them something less effective when I know I could offer them something that works better, even at the risk of being more expensive? It often seems like cost of treatment is literally a small price to pay for one’s health. And yet, as a patient myself, I have no choice but to think about cost as part of the problem — and my patient self has a different perspective than my physician one.
As a patient, I know that cost is often the elephant in the room. During my most recent health incident, I chose a treatment (having a friend come pick me up) that was less ideal than traveling in an ambulance filled with medical professionals. I attempted to reduce costs even when my health could have been worsened. Ultimately, I was fine — a few days later, after drinking some fluids and resting, I felt fully recovered — but that won’t always be the case. Sometimes higher-cost care truly is necessary for a successful outcome. And so, this begs the question: Should patients be allowed to choose the cost of their care — split into length of treatment, efficacy of treatment, probability of relapse — before being treated?
Currently, the U.S. health care system is structured in the opposite way — patients are obliged to accept all medical and administrative costs prior to seeing a clinician. This means the burden is placed on the patient to pay once they sign the financial agreement. Given the competing priorities of health and business, ethical questions are bound to arise. One may wonder: Are we physicians doing patients justice by giving them the best treatments we can offer, despite the financial challenges they will incur? Do we trust that they can make their own health care decisions, when it seems that cost is almost always a factor in decision-making?
These questions have no easy answers. However, I do know that some patients have more reason to be concerned about financial hardship than others — meaning that an emergent health accident or an expensive medication will sink their financial ship and make them less inclined to see a physician. One way we can limit financial hardships, as simple yet difficult as it sounds, is by advocating for more affordable medications. Secondly, we can become aware of medication costs so we can share with patients what the price of medications would be if they were to go with option A or option B. Thirdly, we can continue to educate patients about health and wellness so that they are thinking more proactively rather than reactively.
It is time to no longer distance ourselves from the money talk and cost of care. As physicians, we have a responsibility to our patients to band together to find solutions that can lead us in the right direction.
Do you think physicians should consider cost? Discuss in the comments!
Dr. Ricardo Chujutalli is a family medicine resident in Orlando, FL. He enjoys reading, playing chess, and exercising. He received his Masters in Business Administration from La Sierra University and Masters in Bioethics from Loma Linda University. Dr. Chujutalli is a 2022–2023 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz