Physicians, Patients Frustrated by Unexplained Care Costs

Marcia Frellick

April 26, 2018

NEW ORLEANS — Physician frustration was evident during a session on how to talk with patients about the costs of care on the closing day of the American College of Physicians (ACP) Internal Medicine Meeting 2018.

Patients don't know what costs are coming. And physicians often don't know what care costs because insurance status, type of insurance, negotiated rates, deductible status, and other factors affect specific charges.

When recommending options, doctors must find a balance between optimal care and the financial stress that can prompt a patient to discontinue treatment.

Experts offered resources for estimating costs and provided examples of how patients and physicians can lower healthcare bills.

In a recent HealthFirst Financial Patient Survey, 77% of patients said it is important or very important that they know the cost before treatment. And 53% want to talk about financing options before care.

Patients Want to Know Prices

Unfortunately, few of these discussions are happening.

Of the 1011 adults surveyed in 2017, only 18% reported that any healthcare provider had spoken to them about financing options in the previous 2 years. And 35% of respondents expressed concern about paying a bill of less than $500.

In a 2017 report by Accenture, 46% of patients surveyed reported including out-of-pocket healthcare costs in personal budgets, but only 11% shopped around for competitive prices.

In 2016, out-of-pocket healthcare costs borne directly by consumers rose 3.9%, which is the fastest increase since 2007, according one recent report (Health Aff [Millwood]. 2018;37:150-160). Much of the increase can be attributed to higher deductibles.

Out-of-Pocket Costs on the Rise

In a 2017 analysis by the Kaiser Family Foundation, 24% of people covered by large employer plans reported spending more than $1000 out of pocket on healthcare in 2015, up from 17% in 2005.

Time off work, parking, transportation, cafeteria meals, and childcare must be factored into the overall cost of care, as must the indirect costs of anxiety and depression.

Desiree Bradley, a patient advocate and family adviser at Texas Children's Hospital in Houston, described her own experience seeking care for her daughter who has medically complex issues.

In the previous 2 weeks, her daughter had 11 appointments. "That's 11 copays and 11 days of parking," she pointed out. The ancillary cost for those 11 visits was $1300.

Patients Are Paying for More Than Just Care

"I go to sleep dreaming about the healthcare costs that we may have coming up," Bradley said.

The average deductible for people with employer coverage rose from $303 in 2006 to $1505 in 2017, according to a 2017 survey from the Kaiser Family Foundation.

The timing of services matters when a patient has a high-deductible plan, said Wendy Nickel, MPH, director of the Center for Patient Partnership in Healthcare at the ACP.

"Last year, in January, my son was diagnosed with scoliosis," she reported. "We were following his curve over time and I probably saw the doctor four times. The doctor never talked with me about what the cost of care might be if we had to brace my son. I never brought it up either. It didn't occur to me."

Higher Deductibles Mean Tough Choices

In December 2017, Nickel's son had to be fitted for a brace. "We went to get fitted and it wasn't going to arrive until the beginning of January — when the deductible started again and I would be out of pocket $3000, she said.

"Had I known the mechanisms and talked about costs throughout the year, I might have pushed to have his brace provided in December," Nickel explained. "It ended up that I did push and was able to get his brace on December 29. I take responsibility in this. I was not as engaged as I should have been around the mechanisms of my healthcare plan."

Where to Find Cost Estimates

Five online resources that provide information on costs were recommended by Jessica Dine, MD, a pulmonologist from the University of Pennsylvania in Philadelphia, who collaborates with the ACP on issues related to high-value care.

Healthcare Bluebook gives average cost information, by ZIP code or hospital, on everything from hearing aids to hospital procedures to dental work.

guroo — created by the Health Care Cost Institute, an independent nonprofit research organization, and powered by claims data contributed by insurers — provides national, state, and local prices for healthcare products and services.

GoodRx provides costs at more than 70,000 pharmacies for every prescription drug approved by the US Food and Drug Administration, and also supplies links to coupons.

Medicare.gov provides information useful even to those not on Medicare.

NH HealthCost was developed by the New Hampshire Insurance Department to improve the transparency of healthcare prices across New Hampshire. "I think we'll see more and more of those," Dine said.

Barriers to Cost Discussions

Physicians in the audience shared why conversations about cost don't always happen:

  • Lack of time in already-packed patient visits

  • Lack of knowledge about what care costs

  • The worry that trust will be broken if a physician gets the estimate wrong

  • Concern that patients will be scared off by the price and not continue with care

  • A long-established culture of not talking about prices related to care

  • The priority of physicians to focus on care, not cost

It is hard to talk with patients when expenses can be way beyond a patient's reach, said Kathleen Volkman, MD, an internist from a neighborhood outpatient clinic in Seattle affiliated with the University of Washington.

Some patients — even those with diabetes who need insulin and those with asthma who need an inhaler — stop coming in rather than racking up bills, she told Medscape Medical News.

"The preferred alternatives are sometimes $200 to $300 a month," she explained.

Bias Can Hurt Cost-of-Care Discussions

Unconscious preconceptions can also affect cost-of-care discussions. Dine recommends that physicians take the implicit associations test on the Project Implicit website.

Project Implicit is a nonprofit organization and international collaboration between researchers who are interested in implicit social cognition — the thoughts and feelings outside of conscious awareness and control.

"We are going to assume some patients can pay and some can't, whether because of race, gender, obesity, age, whatever," Dine explained.

Possible Cost-Reduction Options

Patient advocate Bradley told the audience she was able to cut costs by asking a few questions when her daughter had 11 medical visits in 2 weeks for unexplained seizures.

One day, her daughter underwent head-to-toe imaging. The next day, another provider ordered almost the same complete imaging to look for something else. Bradley asked whether the first set of images could be used for the second request and, after referrals to two more providers in the hospital, the answer was yes.

Eliminating the duplication saved her a few hundred dollars. "At the end of the day, we have to make some hard choices," Bradley said. "Some days, I'm faced with deciding whether I'm going to pay my mortgage or provide the care she needs."

Cost-saving options to keep in mind:

  • 90-day refills

  • Prescriptions by mail

  • Change in dosing; for some medications, this will reduce the price

  • Splitting pills when appropriate

  • Scheduling a test and a follow-up visit on the same day to limit transportation costs and save time

  • Scheduling a visit on a day the patient will be at a facility for another reason

  • Price shopping for medications

  • Patient-assistant programs run by pharmaceutical companies

Talking About Costs Can Improve Outcomes

"What are patients going to do if they can't afford your $5000 test?" Dine asked. "They're not going to do it, and then they're going to get labelled nonadherent," she pointed out.

"Conversations are going to improve outcomes because you're going to figure out how to get it done or what to do instead," she said.

Bradley, Nickel, Dine, and Volkman have disclosed no relevant financial relationships.

American College of Physicians Internal Medicine (IM) Meeting 2018. Presented April 21, 2018.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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