The New Reality Of Patient-Doctor Relationships

Doctors, patients routinely discussed payment in days before employer-sponsored insurance

By Richard Craver | Journal Reporter
Published: November 29, 2009

The cost of health care has long been the elephant in the room of doctor-patient discussions.

“Doctors generally avoid asking patients about health insurance and finances because physicians want what they believe is best for their patients,” said Mark Hall, a professor of law and public health at Wake Forest University School of Medicine.

“What’s best might not always be most affordable.”

That’s changing. Millions of Americans have no health insurance, and many of those that do are facing increasing costs, higher deductibles and larger co-pays.

The result: doctors and patients are being encouraged — if not forced — to talk money upfront like they would about buying a set of tires.

Not having the conversation could prove financially devastating. Researchers at Harvard University reported that medical problems caused 62 percent of all personal bankruptcies in 2007. Of those bankruptcies, 60 percent of the filers had private medical insurance.

Then again, having the discussions could open a Pandora’s Box for physicians.

Such as:

□ How much should a physician know about a patient’s job status, or consider the employer’s financial health, in determining ability to afford medical services?

□ Is there financial liability and ethical accountability for recommending the most costly surgical procedure, which could drain the patient’s overall finances if they lose their job and health insurance and can’t afford the bill?

□ Is there financial liability and ethical accountability for recommending a lower-cost option that significantly affects the patient’s quality of life — living with more pain than necessary — or projected lifespan?

□ How much defensive medicine — ordering tests that are borderline necessary to defuse any potential legal action — should be practiced?

Hall studied such issues for three years and co-wrote a report that recently appeared in The Journal of Family Practice.

“Each year, doctors are finding more and more that patients are coming in carrying substantial deductibles and having to pay more out of pocket,” Hall said. Physicians told of patients who left prescriptions unfilled or refused to get diagnostic treatments because they couldn’t afford them.

“Every level of stress needs to be identified and addressed, with job stress often going hand-in-hand with financial stress,” Hall said.

“More physicians are finding a balance of something good enough at a lower cost, such as a generic drug over a brand name. They are using professional judgment with practical wisdom as they provide a tray full of options to their patients.”

…

When asked when a doctor should address medical costs with a patient, she said “always and as often as possible.”

“Ultimately ­– it is the patient’s choice — but being informed well of the options, possibilities, treatment, recovery, etc., is important. Why wouldn’t all patients wish for this type of care?”

“We have to be persistent in wringing out what costs we can, to come up with other alternatives, which sometimes takes some creativity,” Long said.

“But that’s true of many of my patients in this economy. There’s no question patients are having to portion out their health-care dollars.”

Freda Springs, a spokeswoman for Novant Health Inc., said that its physicians view discussing health-care costs “as an obligation in caring for the whole person.”

“Patients will often confide in their physician when they will not confide in others,” Springs said.

“What we try to do is coach our physicians to ask pertinent questions, and if they believe the patient needs assistance, to get them to the customer-service navigator while they are in the office.”

Families USA, a consumer-advocacy group in Washington, recently released a consumer guide that offers strategies, tips and warnings to consumers to manage medical debt and avoid bankruptcy.

“Medical debt is a stealthy fiend, striking unexpectedly and feeding on both a family’s rising health-care expenses and what may be a growing inability to pay because of a loss of a wage earner’s income,” said Ron Pollack, the executive director of Families USA.

The group said that medical debt is a growing problem for both people who are uninsured and people who are underinsured — those with coverage with high deductibles, high co-payments, many uncovered benefits, and what it considers as insurers’ arbitrary limits on coverage.

Pollock said that medical debt contributes to mounting credit-card debt and can threaten a family’s housing security by putting rent or mortgage payments out of reach.

Dr. David Miller, an associate professor at Wake Forest who focuses on general internal medicine, treats mostly low-income patients at the Downtown Health Plaza.

Five years ago, he was the one initiating conversations on the cost of treatment.

“Nowadays, it’s more like 50-50,” Miller said. “It often starts when I begin to recommend a course of treatment. They are more upfront about saying ‘I really don’t have a lot of money right now.’

“It’s most uncomfortable when I talk with patients who want to put off further treatments for several months, or don’t get a prescription filled, because of concerns about cost.

“There are others who put off treatment out of a hope that they’ll land a job with health benefits by the time something might get serious,” he said.

A recent study of North Carolina employers by Mercer Human Resource Consulting found that they expect to pay a smaller increase in employee health-insurance costs next year.

The survey of 99 North Carolina employers — all with at least 10 employees — found an average projected increase of 4.7 percent over 2009 costs. The employers said they expect to achieve that goal by passing on more costs to their workers or by changing insurance plans or insurers.

Without making those changes, the average increase would be 7 percent.

Steve Graybill, a Mercer senior consultant, said that consumers could “benefit immensely” from having a discussion on the cost vs. the benefit of treatment options.

“That way, the doctor and consumer can agree upon an informed course of action,” Graybill said. “Most insured consumers do not even understand their maximum out-of-pocket cost should they have a major event.

“We will be unable to get medical cost under control unless we are all more educated on the cost of treatment.”

Hall said he encourages patients to bring up financial concerns in the examination room.

“You shouldn’t be afraid to talk to doctors about having to pay for things,” he said.

It’s not like having those conversations would be groundbreaking, Hall said. Several generations ago, before employer-sponsored health insurance was standard, doctors hashed out payment with patients daily.

Hall said that many doctors need training on how to effectively talk with patients about money.

“The experienced physicians interviewed for this study suggested asking patients not about ability to pay, but instead about the extent of the patient’s insurance coverage,” Hall said.

“That way, they could avoid the embarrassment some patients feel admitting they can’t afford their doctors’ bills. This is just a fact that the doctor wants to know about.”

Hall said that by having the cost conversations, “if a patient subsequently chooses to take a cheaper route, there’s little chance of a lawsuit because the choice is ultimately for the patient, not the doctor, to make.”

photo credit: The Library of Congress