By not making potential expense a part of the conversation regarding treatment options, doctors are exposing patients to financial troubles that could compound their health struggles, the Duke physicians wrote in an opinion piece in the Oct. 17 New England Journal of Medicine.
"Since health care providers don't often discuss potential costs before ordering diagnostic tests or making treatment decisions, patients may unknowingly face daunting and potentially avoidable health care bills," the physicians wrote. "Because treatments can be 'financially toxic,' imposing out-of-pocket costs that may impair patients' well-being, we contend that physicians need to disclose the financial consequences of treatment alternatives just as they inform patients about treatments' side effects."
The physicians argue that doctors should consider financial discussions part of their traditional duties, even if they need to receive more training to better understand the expense of treatments to patients.
Nearly two-thirds of personal bankruptcy filings in the United States are due to medical debt, according to the nonprofit National Patient Advocate Foundation. Families run up overwhelming medical bills treating a seriously ill loved one.
Previous studies have shown that more than half of patients want to talk with doctors about the costs of treatment options, but only 19 percent actually have that conversation, said paper co-author Dr. Yousuf Zafar, an assistant professor with the Duke Cancer Institute and the Duke Clinical Research Institute, in Durham, N.C.
"Even though patients have this desire to bring up their growing financial burden, they hadn't had the discussion," Zafar said. "Patients say they want the best care regardless of cost, but in their mind, they link cost to quality. They believe the best care is the most expensive care, and if they talk about cost they might not get the best care."
Zafar began looking into the role of financial information in medical decision-making based on feedback he received from his own patients.
"Patients in my practice as a medical oncologist were coming to me with growing concerns about the cost of their care despite having insurance," he said. "We as physicians don't really know what all of the costs are, but that doesn't mean we shouldn't bring up the topic."
One in five Americans is underinsured, paying at least 10 percent of their annual income on out-of-pocket health care expenses, Zafar said. A serious illness could ruin these people financially.
Reviewing the potential out-of-pocket costs of a procedure can be beneficial to patients, the authors said, by enabling the following:
- Helping them choose lower-cost treatments when there are viable alternatives.
- Assisting those who want to make an informed decision about trading potential medical benefit for less financial distress.
- Allowing them to prepare themselves financially for an expensive procedure.
"Patient expectation plays a role in their level of financial distress," Zafar said. "If patients expect to pay a lot, they are able to cope better. If we prepare patients for the cost, even if we can't reduce the cost, preparation can go a long way."
Further, by considering costs in individual cases of clinical decision-making, doctors could play a crucial part in reducing overall health care costs for society as a whole.
Such conversations would be welcomed by patients, said Kim Bailey, research director for Families USA, a nonprofit health care advocacy group.
"Providers have been really hesitant to talk about cost, and they haven't thought a great deal about cost when talking with their patients about care," Bailey said. "In some ways, it's been seen as the provider's role is to focus solely on medicine, and that discussions of cost is really an insurance role."
It may take some training to help doctors grow comfortable adding a financial dimension to discussion of medical options, paper co-author Zafar said. Medical societies, advocacy groups and medical schools should consider playing a role in such training.
"It's a sensitive topic. It's embarrassing for many patients. And we as physicians don't have the knowledge base to talk about cost," he said. "But we give patients chemotherapy that we know is going to cause a physical toxicity we can't stop. We talk with them about how to best cope and expect it. That's how we should start thinking about the financial toxicity of some of the health care we provide."
For her part, Bailey suggested that physicians daunted by the overwhelming complexity of cost-sharing and different insurance plans might want to start the discussion by asking general questions about patients' financial concerns.
"Maybe the conversation could start there," Bailey said. "'Are you worried about the cost of your treatment? If so, have you looked into what your plan covers?'"
Families USA has suggestions for dealing with medical debt.