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A non-compliant patient arrives at the emergency department (ED) for evaluation of high blood pressure. Why isn't she taking her medication? It costs $300 per month, and she can't afford it. Has she talked to her doctor about a less expensive alternative? No.
Unfortunately, this type of interaction occurs far too frequently. The doctor would be happy to prescribe a cheaper alternative if requested, and the patient would love a cheaper option but doesn't want to question the doctor. It's a Catch-22 that even Heller would appreciate.
A simple conversation about the cost of treatment, the patient's insurance status, and their ability to pay would easily solve the problem. As physicians, we must learn to discuss these money matters with our patients.
Why Is It Difficult for Physicians to Talk About Money?
Everyone has a difficult time talking about money, and physicians are no different. We may worry that patients view us as "rich" and out of touch. We also don't want the patient to think we only care about money. However, the most significant barriers are ingrained in our medical education and healthcare systems.
Philosophy
Medical school and residency teach us not to think about money. In many ways, this is a good thing. We are trained to treat everyone equally regardless of race, religion, sexual orientation, or socioeconomic status. In the ED, we treat everyone regardless of their ability to pay. For years, I prided myself on not knowing my patients' insurance status. I would get slightly offended should a consultant ask me. I now know that despite coming from a good place, this perspective is naive.
Ignorance
Most of us don't know how much the medicine we prescribe or the tests we order cost. This is partly because the cost of anything in our healthcare system is opaque. Different prices exist depending on whether the patient has insurance, and each insurance company negotiates rates with individual hospitals and clinics. It's also partly because we aren't taught this in our training and haven't taken the time to learn independently.
Additionally, many providers simply don't understand how insurance and medical billing work. They don't know what the patient is being charged and probably don't know how to find out. Patients who ask what their ED bill will be are typically met with a blank stare.
The 'Best'
We generally prescribe what we think is "best" for our patients without regard to price -- the best test, medicine, or intervention. However, unless the recommendation includes a discussion about the patient's ability to afford it, the "best" is potentially useless. I would rather prescribe my patient the fourth-best blood pressure medicine that she can afford than the absolute best she cannot.
The very idea of the "best" is nebulous. What many physicians believe to be the best is simply the newest or most heavily marketed. Doctors are as susceptible to marketing as anyone else. Drug companies have a vested interest in their latest medications being perceived as the most efficacious and in doctors prescribing them. Many new medications are simply a variant of an existing one, often created when the established medication's patent expires. Even if the studies show increased efficacy at the margins or slightly fewer subjective side effects, it may not justify the increased cost.
Time and Habit
Doctors are busy. Seventy-four percent of physicians are now employees who carry that burden. We have a boss and specific metrics we must meet. Doctors are constantly pushed to do more in the same amount of time. Those in private practice feel the same pressure to keep their business financially viable. So, we all create habits and shortcuts. There are literally thousands of medications, so we develop a routine of repeatedly prescribing the same things. It's a lot easier to remember 50 medications than 500. We do the same for tests. How many of us use order sets that depend on the patient's complaint? Not every test may be necessary for every patient, but it is easier and faster just to order them together.
What Medical Providers Should Do
What can a provider do to help ease their patient's financial burden? I recommend the following three steps.
- Educate yourselves. Do you know how much the medications you prescribe cost? Do you know your patient's insurance status? If a patient doesn't have insurance or has a high-deductible plan, they're unlikely to take the $300-per-month medicine you prescribe. Learn how insurance and medical billing work. Find out what your employer charges for every test and medication you prescribe. An intramuscular shot of penicillin G benzathine (Bicillin L-A) may be $200, while a prescription for penicillin V potassium costs $20 or less.
- Get uncomfortable and assess your practice. Stop practicing based on habit. Review every protocol and "order set" to see if there are any unnecessary tests or those that may be applicable only under certain conditions. Reassess the medications you routinely prescribe to determine if there are cheaper alternatives that are still effective. Ask yourself the hard questions. Do I need to refer this patient to a specialist, or can I handle this with some research? Do I need to order that $700 viral panel, or can I take the time to explain that it is unnecessary?
- Get comfortable talking about money. We talk to patients about intimate details -- drug use, sexual activity, bodily functions, etc. I ask teenagers about sexual activity in front of their parents, and grandmas about drug use. How much more difficult is it to say to a patient, "Can you afford this medication? Do you have any financial concerns about following this treatment plan? There are less expensive alternatives available." You don't have to worry about bias if you ask every patient.
Conclusion
I'm not recommending substandard care. I'm suggesting that an open dialogue about money can build trust, improve compliance, and lower patients' costs. We need more than money conversations to solve healthcare's affordability crisis, but we have to start somewhere.
Neill Slater, MD, is an emergency physician.
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