Discuss Costs of Tests and Therapies With Patients

Roxanne Nelson

October 17, 2013

Surely it is a mistake for a simple Pap test to cost $1000. Yet this can be the bill presented to a patient if a physician requests a few other tests at the same, simply by ticking some boxes on the same form.

This illustrates why physicians need to be aware of the financial effects their orders have on patients, according to 2 perspectives published in the October 17 issue of the New England Journal of Medicine. They discuss how physicians need to increase their understanding of this issue, why costs need to be discussed with the patient, and the role that physicians can play in helping to reign in costs.

The $1000 Pap Test

How a $20 to $30 Pap test can leave a patient with $1000 bill is discussed in one perspective by Cheryl Bettigole, MD, MPH, a family physician and chief medical officer of the Complete Care Health Network in Bridgeton, New Jersey.

Ordering lab work has never been easier, and expensive and unnecessary tests can easily be ordered simply by ticking boxes on a form, she writes.

Laboratories have been touting "improved" tests, virtually all of which involve combination panels that can be ordered very easily and contain extensive lists of "fairly esoteric" tests. In the past, these tests would have required multiple specimens, Dr. Bettigole explains.

"Nothing at any point along the way alerts either the clinician or the patient to the high costs of these tests or to the fact that there is little medical evidence to suggest that they are useful for most patients," she notes.

For example, "the single-vial women's health test is being heavily marketed by multiple laboratories. It includes not only the Pap and HPV tests, but also tests for multiple infections — including some we would rarely have tested for in the past — for which we often have no evidence of benefit," she adds.

The unfortunate result is that many women are choosing to forgo screenings because of the financial consequences. "As healthcare costs grow and laboratories develop savvy marketing tactics resembling those deployed by pharmaceutical companies, it is becoming increasingly clear that physicians have an obligation to be good stewards of limited resources and to understand the financial effects that the orders we write have on our patients," she writes.

Failing to do so not only means burdening patients with large bills, it will also affect the "gains we have made against cervical cancer and many other conditions," Dr. Bettigole concludes. "We contribute to spiraling healthcare costs and are doing real harm."

An Unmentioned Adverse Effect

The other perspective tackles the out-of-pocket costs of treatment. Out-of-pocket costs tend to be most pronounced in cancer, although patients with other types of complex illnesses are also hit with this burden, write the authors, headed by Peter A. Ubel, MD, professor of business administration and medicine and public policy at Duke University in Durham, North Carolina.

They highlight a stark example — in Massachusetts, out-of-pocket costs for breast cancer treatment can be as high as $55,250 for women with high-deductible insurance plans.

Physicians generally discuss the potential adverse effects of treatment at length with the patient before treatment starts, but rarely discuss out-of-pocket costs associated with treatment. Many physicians don't include information about the cost of care in the decision-making process, and do not mention that there are often less expensive options or patient-assistance programs.

They should do so, Dr. Ubel and colleagues assert. Potential financial stress associated with paying for treatment should be discussed with patients, in the same way that treatment-related adverse events are discussed, they write. Treatments can be "financially toxic" when they affect a patient's well being by imposing unaffordable out-of-pocket costs.

In addition to discussing out-of-pocket costs, physicians need to be cognizant of the financial effects the orders they write have on their patients. "Even in this era of patient empowerment, physicians have a huge influence on the decisions that their patients make," said Dr. Ubel in an audio interview posted on the Journal's Web site.

He explained that most of the time, physicians are busy taking care of their patients and offering them the best possible medical care. "To us, best usually means best medical outcomes," he said. "We forget that sometimes we can pursue the best medical outcome — morbidity and mortality — but if the treatment is really expensive, your patient might suffer more than they would otherwise. It could have a bigger impact on their quality of life than the modest improvements you made in their health."

He pointed out that some physicians are hesitant to discuss finances with their patients "because they have very understandable fears that it will look like they are judging the value of the patient's life. But it depends on how you put it."

In fact, patients can experience unnecessary financial distress when physicians do not inform them of alternative treatments that are less expensive but equally or nearly as effective, Dr. Ubel explained in the interview.

Dr. Ubel and his colleagues "discovered this phenomenon" when interviewing a sample of breast cancer survivors who had participated in a national study of financial burden. Many patients reported that they only began discussing costs after experiencing financial distress. One woman reported that she was offered an alternative therapy that was less expensive but equally effective only after she had told her physician that she was not going to take a drug that cost her $500 a month.

They point out that discussing out-of-pocket costs up front could help patients seek financial assistance early enough in their care to avoid financial distress. In addition, there is a growing body of evidence suggesting that including financial factors in clinical decision making reduces the cost for patients and for society in the long term.

"We have 2 things that we would love to do in our healthcare system," said Dr. Ubel in the interview. "We'd love to hold down costs and we'd love to keep making important advances to improve the health and well being of our patients."

Unfortunately, these don't go hand in hand. The more costs are reigned in, the less incentive industry has to develop new products, he added. "At some point, we have to decide how much it is worth to invest in the future health of our patients."

N Engl J Med. 2013;369:1484-1486, 1486-1487. Bettigole full text, Ubel et al full text

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