Cost of Care Should Matter to Doctors, Too

This article by guest writer Dr. Vic Reddy is re-posted with permission from the Detroit Free Press.

Docs should care about drug prices tooI had just finished a consultation with a patient about a proposed procedure when she asked, “Well, what’s it going to cost me?”

I looked at her insurance, one offered through our state’s health insurance exchange; the plan had a significant deductible, and I could tell she was hedging on what was an elective procedure. I asked our office manager to give her an approximate charge based on my fee and what the hospital would charge. The patient left satisfied and said that she would consider whether she would proceed.

In the past, I would normally have demurred if a patient had asked me the cost of a procedure or a medication. In medical school, the cost of medical care was never part of my education, and, in many academic medical centers, some physicians take a certain amount of pride in being able to deliver “cutting edge” care which is, often, also the most expensive.

For most physicians, however, the choice to not have a frank discussion about costs comes down to a philosophical one: Should a doctor really consider cost when it comes to taking care of patients? One argument often cited is that any consideration of cost will taint the relationship a physician has with his or her patients. If the fundamental tenant of being a physician is to provide the best possible care, tempering this with a consideration of cost might serve to undercut it.

When I was a surgical resident, a patient without insurance was admitted for emergency surgery. The patient developed a post-operative infection, which required weeks of intravenous antibiotics. When I saw the patient in the clinic for a follow-up, she informed me that she was worried about the cost of the medication. When I informed my attending physician, he told me emphatically, “Our concern is taking care of her, not what the hospital will bill her. Put the patient’s health first.” Like most residents, I took my attending’s words to heart, and made it part of my own personal code. I would even relate the story to my residents and medical students, though I never achieved my attending’s patrician delivery.

After years of practicing medicine, however, I believe he was incorrect. Taking into account what a patient has to pay is putting the patient first. Moreover, the belief that doctors can separate the cost of care from treating their patients is a fallacy. Patients have always had to face cost limits: A medicine that is not on an insurance plan’s formulary would be considerably more expensive; seeing a non-network physician could be done, but a patient would face a much higher bill. If a physician were to prescribe a medication that a patient cannot afford, the patient will not be able to comply with the treatment regimen — is that providing the best possible care for a patient?

In the current environment of consumer-driven health plans and catastrophic-coverage plans, patients have much more skin in the game. The patient, however, is at a significant disadvantage due to the byzantine nature of medical billing. Several articles recently have pointed out the cost an uninsured patient may have to face when receiving medical care. What has received less coverage, however, are the difficult choices facing patients with these high-deductible plans.

A recent survey by the Commonwealth Fund reveals that often people with high-deductible plans will delay seeking care because of the out-of-pocket costs they face. Some health economists would argue that the design of high-deductible plans is meant to dissuade overuse of health care services. Others would argue that the asymmetric knowledge of medicine puts the patient in the terrible spot of having to decide what care is “worth” the cost. Regardless, what patients need in this paradigm is a clear definition of what the costs are.

The phrase “consumer-driven” health plans makes it clear that the patient is given a choice as a consumer, but how can one shop for health care without an understanding of how much they will pay? Though quality in medicine is frequently shared through publicly reported outlets, such as Healthgrades, cost remains in the shadows. Physicians, hospitals and health insurers owe it to their patients to be as transparent about costs as possible. Transparency of what a patient will be charged can lead to innovation in how health care is delivered and decrease the fragmentation and redundancy we all face every day.

Vik Reddy is medical director of quality and clinical integration at Henry Ford Macomb Hospital.

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