Doctor, First Tell Me What It Costs
If an antibiotic would cure your infection, your doctor would probably still warn you about the chance of sun sensitivity before prescribing the pill.
But even when the costs of a medical intervention might force patients to choose between paying the bill or keeping up with their mortgages, American physicians rarely discuss that serious side effect with them. One physician recently explained to me that he felt money talk would “violate the doctor-patient relationship.”
Given how much attention we have been focusing on health care costs and the Affordable Care Act, now is the time to change such thinking.
In The New England Journal of Medicine last month, two colleagues and I wrote an essay intended for physicians; we argued that they should discuss out-of-pocket costs with patients just as they discuss any side effects. After all, the financial burden of paying for medical care can cause more distress in patients’ lives than many medical side effects, and patients can decide whether any of the downsides of treatment are justified by the benefits.
Take, for example, a patient with colon cancer whose oncologist is considering prescribing Avastin. Most physicians would go out of their way to warn that this drug could harm a patient’s heart; the data show that it carries a 2 percent risk of cardiovascular toxicity. But few physicians would discuss the price, even though Avastin can cost more than $50,000 per patient, and a Medicare patient without supplemental insurance could be responsible for nearly $9,000 of that.
The Affordable Care Act will have only a modest impact on patient exposure to health care costs because the limits it sets on out-of-pocket costs are still high compared with most people’s resources. And in the last six years, according to the Kaiser Family Foundation, we’ve seen a threefold increase in the number of people choosing high-deductible plans.
The Center for American Progress estimates that a breast-cancer patient in Massachusetts with a high-deductible plan could face more than $50,000 in medical expenses. That’s more than the average lifetime savings of the majority of American families.
In our New England Journal article, we tried to convince physicians that they needed to start incorporating the cost of care into their clinical conversations. But patients should not be afraid to take the lead and ask how much a pill or procedure will cost. Far too often, patients bring up such questions only after they have already experienced treatment-related financial distress. My colleagues and I confirmed that during interviews with breast cancer survivors; in a number of cases, the physician had told the patient that if she had only mentioned a concern about the cost earlier, the doctor could have suggested less expensive alternatives.
That kind of lapse should never happen. No one should have to suffer unnecessarily from the cost of medical care. Simply put, discussing costs in the doctor’s office is good medicine.