Talking about money is never easy. But when doctors are reluctant to talk about medical costs, a patient’s health can be undermined. A study published in Monday’s Health Affairs explores the dynamics that can trigger that scenario.
Patients are increasingly responsible for shouldering more of their own health costs. In theory, that’s supposed to make them sharper consumers and empower them to trim unnecessary health spending. But previous work has shown it often leads them to skimp on both valuable preventive care and superfluous services alike.
Doctors could play a key role in instead helping patients find appropriate and affordable care by talking to them about their out-of-pocket costs. But, a range of physician behaviors currently stands in the way, according to the study.This KHN story also ran on NPR. It can be republished for free (details).
“We need to prepare physicians to hold more productive conversations about health care expenses with their patients,” said Peter Ubel, the study’s main author and a physician and behavioral scientist at Duke University.
The researchers analyzed transcripts of almost 2,000 physician-patient conversations regarding breast cancer, rheumatoid arthritis and depression treatment. They identified instances in which patients suggested that the cost of care might be difficult to afford and assessed how doctors responded.
Overall, researchers noted two ways in which doctors dismissed patients’ financial woes. They either did not acknowledge the concerns patients expressed or only half-addressed them. For instance, if a patient commented on how expensive a drug was, the doctor might ignore the comment entirely or might suggest a temporary solution — like a free trial — without exploring long-term strategies to address the issue.
And, without such a long-term plan, patients may eventually stop taking the medication, or take it irregularly. That can harm their health, and even send them to the hospital.
The study doesn’t measure how often doctors dismissed patient concerns — because, the researchers wrote, they didn’t know how often those dismissals led to people actually foregoing needed treatments.
Still, Ubel said, it is clear doctors are not talking to patients about these expenses. He pointed to a separate analysis of those same conversations, which found that doctors discussed medical costs with patients about 30 percent of the time; and, in only about 40 percent of those discussions did doctors and patients brainstorm about ways to make medication more affordable.
“A majority of [physicians] — they don’t talk about costs,” he said. “When they do talk about it, they don’t talk about it productively.”
Why do physicians hesitate? For one thing, they aren’t used to discussing cost barriers, and many think it’s inappropriate to bring up money at all, Ubel said. When he lectures on the subject, he always encounters people who worry discussing finances will “contaminate the doctor-patient relationship.”
Plus, doctors haven’t been taught to listen for patients’ pocketbook concerns. If a patient comes in with heartburn and indigestion, a good internist will immediately start probing for signs of coronary disease, Ubel said. By contrast, physicians aren’t primed to pick up on cues that patients may face financial strains.
“If we had that on our list to be aware of, we’d pick up the cues. If we don’t, it’ll be right in front of our eyes, and we’ll miss it,” he added.
The idea of patients acting as consumers — weighing cost and shopping for the best health care deal — is still relatively new, the study notes. As it becomes more commonplace, patients may push doctors for more help in making cost-based decisions, Ubel said.
That said, navigating a patient’s financial circumstances and medical needs in the course of a 15-minute visit is tricky, said Jonathan Kolstad, an assistant professor of economic analysis and policy at the University of California, Berkeley. Kolstad wasn’t involved in the Health Affairs study but has researched how medical costs affect people’s decision-making.
“It’s not as though, ‘Oh, it’s just consumers can’t figure it out.’ Doctors don’t know,” he said. When it comes to figuring out what a drug will cost, “doctors are in the same boat.”
The idea of comparing prices and quality when we are in the market for health care is pretty new territory in our country of avid shoppers. But more and more employers and insurers are giving patients tools that let them put in the name of a test or procedure and see who charges what.
So what are patients shopping for? A study out Monday looked at the health care shopping habits of 332,255 members of the insurer Aetna in 2011 and 2012. The top shopped service was a colonoscopy. Coming in at second and third, respectively: a mammogram and childbirth services.
Patient shoppers were typically younger, healthier women who had a high deductible plan and had time to plan ahead. But overall, only about 3 percent of those who had access to Aetna’s “Member Payment Estimator” used the tool — even though surveys show patients want prices.
“This suggests that our efforts to engage patients with price information are still very much a work in progress,” one of the study’s co-authors, Anna Sinaiko, said in an interview. She’s a research scientist in the Department of Health Policy at Harvard’s T.H. Chan School of Public Health.
Sinaiko said patients often do not know where to find a price at the time they are making an appointment or choosing a hospital.
“This question of how to get this information to patients is the key one going forward, and continuing to fill this gap is the important work that lies ahead,” Sinaiko said.
Most health care comparison tools offer limited quality information because few reputable organizations have determined how to measure quality and collect the numbers.
We have some quality data that we’ve previously collected and published on colonoscopies, mammograms and childbirth. At the very least, we hope this will help you ask more informed questions if you are trying to figure out where to find the best value for your health care dollar.
The study appears in the April issue of the journal Health Affairs.Our Past Quality Measures Reporting: