Healthcare organizations shifting to wellness and value-based care first have to overcome significant barriers in getting certain populations to engage in health improvements. But among the biggest barriers today is one that few physicians seem willing to discuss with their patients: cost.
Despite the efforts to overhaul insurance, high-deductible health plans (HDHP) seem to be the trend of the future. According to a study by the National Center for Health Statistics at the U.S. Centers for Disease Control and Prevention, the percentage of privately insured American adults aged 18 to 64 with HDHP has risen from 26.3 in 2011 to 39.3 percent in 2016--a nearly 50 percent increase in HDHP insured people.
As a result of this growing concern around the cost of healthcare, more healthcare consumers are recognizing how mind-bogglingly difficult it can be to find a cost associated with any type of healthcare. In fact, a February 2017 Monmouth University poll found that 25% of American families point to paying for healthcare as their top concern, topping job security and other household bills in causing the most anxiety for American households.
And a March 2017 survey from the Kaiser Family Foundation found that 43 percent of adults with health insurance report having difficulty affording their deductible; roughly a third said they have trouble affording their premiums. This leads many Americans to delay or skip needed care due to costs. Twenty-seven percent of the Kaiser survey respondents said they put off or postponed getting healthcare they needed due to high costs, 23 percent said they skipped a recommended medical test or treatment, and 21 percent said they have not filled a prescription for a medicine.
Physicians already have a responsibility to educate their patients on how best to care for themselves. Should wellness advice be extended beyond getting exercise and watching diet to offering resources that help navigate the financial vagaries of healthcare?
Do physicians have a responsibility to educate their patient on how to get quality care that is also cost effective?
The Missing Step in Treating Patients as Consumers
The healthcare industry has been adamant that in order to stay viable, providers must treat patients as consumers. Healthcare systems are focused on putting outpatient locations close to their patient population to make care more accessible. Hospitals are being furnished with hotel-like amenities and restaurant quality food.
But the industry’s focus on treating the patient as a consumer may be missing an important point. When shopping for virtually any other product or service, consumers want to know the cost of what they’re buying.
A 2003 JAMA study found that both patients and physicians believed that discussions of out-of-pocket costs to be important, but rarely held these discussions.
In a survey of 484 outpatients and 133 general internists, 63 percent of patients reported wanting to talk with their physician about their out-of-pocket costs, and 79% of physicians believed that patients in general want to discuss these costs. Yet only 35% of physicians and 15% of patients reported having these discussions.
“Physician communication with patients about out-of-pocket costs may be an important yet neglected aspect of current clinical practice,” the researchers concluded.
Physicians are still calling for this change to take place.
Christopher Moriates, M.D., the assistant dean for healthcare value in the Dell Medical School at The University of Texas at Austin, made a call to action in a recent editorial for Dallas News to make the cost of services a greater part of the patient-provider conversation.
“More doctors should care about the costs that patients need to pay, and help with ensuring that the recommendations they make are the best options for the patient sitting in front of them,” Moriates said. “For example, there are wide arrays of choices for many medication classes, such as statins or oral contraceptives. Physicians can help identify the option that will be the most cost-effective for a given patient. Healthcare professionals also can learn and share specific ‘tips’ with patients, such as informing them about the $4 generic medication lists from Target, or Costco drug price lists.”
The first step to bridging this disconnect, however, is encouraging, and educating, physicians on how to engage in this discussion.
“It’s clear that as patients are increasingly adopting high deductible health plans like never before,” Moriates tells PSQH. “We hear patients increasingly bringing up concerns around costs in clinics. But there’s actually research that’s been done, where they’ve recorded conversations between patients and their physicians, where it turned out that a lot of times when patients did indeed bring up the topic the physicians in general either ignored it or deflected or answered in a non-helpful way.”
Moriates points out that physicians have traditionally been taught that price is not their responsibility and shouldn’t factor into medical decisions. “It’s clear that’s no longer providing the best care for our patients,” he says.
There are barriers to break down to make these discussions a more regular, and accepted, part of care. There are concerns that patients will make decisions unduly focused on cost. There’s of course the fact that physicians already have overly limited time for patient interaction that makes it difficult to cover this information. And discussing money is a sensitive topic. But as Moriates notes, “physicians take responsibility for discussing all kinds of sensitive topics. We screen for domestic violence and alcohol abuse, and we have challenging conversations about opiates and all kinds of stuff so this seems odd to me that this is one that we would shy away from.”
However, the biggest issue may simply be that few physicians have insight into the cost challenges their patients are facing and have little understanding of how to answer the questions posed to them.
Creating Cost Solutions
Bill Kampine, co-founder and senior vice president of Healthcare Bluebook, a company dedicated to providing price transparency for healthcare services, explains the problem like this: “For a cataracts surgery, for example, your surgeon through Blue Cross/Blue Shield might get paid $450 per eye for that surgery. It doesn’t matter where your surgeon does that surgery, if it’s in the hospital or outpatient or ambulatory surgery center, he or she still gets that $450 for that eye surgery. The issue is that depending on the building you walk into—whether you’re on the hospital campus or across the street at the ambulatory care center—the facility fee is vastly different.
“The cost for that surgery at the ambulatory surgery center that’s in the network could be $1,500, but if your surgeon does that surgery on the hospital campus that facility fee might be as large as $5,000. So the big price differences are attached to the building where you go for care, not necessarily to your doctor,” Kampine says. “Most doctors only know what they get paid—that $450—and they get paid the same thing anywhere. “
The solution, Kampine points out, is often very simple, as simple as rescheduling the appointment. But it takes knowing this price difference and incorporating this conversation into the broader care discussion.
Providing this type of education is one of the core missions of Costs of Care, a national nonprofit. Founder Neil Shaw, at the time a resident at Harvard, realized that few physicians seemed to know anything in medical delivery about cost. “Initially it was meant to open the discussion,” Moriates, who also serves as Costs of Care’s implementation director, explains.
The organization gathers stories from caregivers and patients to put a face on the problem and demonstrate that discussions about cost is not just a national resource problem, but is one affecting individual people and their ability to get quality care. “We’re trying to reframe the problem and talk about how this really is a problem at every level,” Moriates says.
The organization also now offers free modules that help physicians change their approach to better engage in these types of conversations. They’re also actively working to better understand how healthcare professionals can be engaged in improving affordability for patients.
“We’re trying to bring together stakeholders and understand what are the resources, what are the models, what are the guides that we need to start addressing this problem and having these conversations,” Moriates explains. “How do you identify those who are going to have trouble paying for healthcare and help them overcome those barriers and plug them in so that they can actually get the care they need?”
Facilitating the Discussion
For some providers, arming an in-office person with information that balances scheduling with cost could build new levels of value into their services and provide a significant competitive edge.
“The doctor and their scheduler at the desk are trying to be helpful to the patient,” Kampine points out. “They may have to get precertification to make sure the patient can have the surgery and they of course want to use an in-network facility and then they’re going to say ‘when do you want to have this done?’” Providers have to understand that for some patients this may be a loaded question.
“We have learned that the physicians don’t [often] understand the implication of price for the patient, depending upon where they schedule the service or where they go,” Kampine says.
A number of new tools are emerging to make cost discussions, and transparency, easier for both patients and physicians.
GoodRX, a free website and application, provides local searches to find the lowest-cost pharmacy for specific prescriptions. In New York City, UMA Health is helping uninsured and underinsured consumers looking for a medical professional learn providers’ rates before booking. In addition to Healthcare Bluebook, Guroo is another website that aims to provide a search of medical prices within a set area to help consumers determine a fair price.
However, these tools are largely aimed at educating consumers. As greater headway is made into this space, more providers can expect their patients to approach them expecting answers to their questions about cost.
“I think it is to some degree our job to educate consumers and make sure that they express that concern and have that conversation with their physician,” Kampine says. “The great news is that the evidence that we have from working with doctors shows that when doctors know there’s a big cost difference they are very happy to make better more cost-effective referrals for their patients.”
Megan Headley is a contributing writer to Patient Safety & Quality Healthcare.