In a large lecture hall of fellow clinicians-to-be, I was told that my job as a physician is not to be concerned with costs but rather to treat patients. My wrist, moving frantically left to right on my page taking notes, stopped. I looked up and my mind wandered: What an odd message to tell those who will be listening to ill people's symptoms, prescribing medicine, ordering tests and orchestrating people's care to not worry about.
We have set up this dichotomy of treating the patient or being concerned with costs. We have soaked medicine with the belief that cost-conscious care is rationing at the bedside and the public is fed fear messages that clinicians who care about costs are limiting their care. How can we teach future clinicians to be so out of touch with one of people's greatest concerns when seeing a clinician? We know that people forgo medications because of high prices, medical bankruptcy plagues many and some cannot seek care due to cost. What other industries allow someone so crucially involved in controlling costs immunity from worrying about them? Does medicine's unique role of saving lives exempt it from keeping an eye on the register? Is good care not cost-conscious care?
Clinicians do not have the luxury to not care about costs. The American Medical Association and the American College of Physicians realize this and are blurring the line between the "treat patient" or "be concerned with cost" dichotomy. They are framing the argument of physicians caring about costs as an ethical issue of the stewardship of limited resources and of providing parsimonious care by using health care resources wisely. This is a good first step, because bringing costs of care out of the dark eliminates this taboo, hush-hush culture of who's paying the health care bill when it arrives at the table. Programs across the U.S. recognize this, too, and are weaving into their curriculum how physicians can be aware of costs in medicine. Research is advancing in this area as we explore in greater detail why prices vary so much: implementing comparative effectiveness research, continuing consumer-driven health care efforts and piloting interventions to control health care costs, like holding health communities accountable for the care that they provide. National campaigns like the American Board of Internal Medicine Foundation's Choosing Wisely call attention to unnecessary care. We have seen health care costs become more exposed with Steven Brill's Time article revealing the rates that hospitals bill to patients or use as a starting point for negotiations with insurance companies. And the Centers for Medicare and Medicaid Services made public charges for 100 of the most common inpatient services and 30 common outpatient services, displaying variations in charges across the country for services.
This is not enough though. We need to continue to build this cost-conscious culture in the exam room where medical decisions are made, including both the patient and clinician, because 1) people care about costs; 2) the medical industry is not exempt from concerns about costs; and 3) good care is cost-conscious care.
People care about costs. People have premiums to pay, co-pays to fork over, deductibles to reach, prescription drugs to purchase and co-insurances to manage. This is a lot of financial information for people to keep straight and to be in charge of on top of the responsibilities they have to manage an illness or care for a loved one. We worry about how much health care services will cost us. In May 2012, the Henry J. Kaiser Family Foundation reported that a quarter of polled people had difficulty paying medical bills in the past year. Six in ten have "cut corners" to avoid health care costs, such as skipping a recommended medical test or filling a prescription medicine. As one might imagine, it's even worse for those who are uninsured, have lower incomes and are in poorer health. Clinicians need to be on the same page as their patients: Costs for their health care matter to them, and people may be afraid to talk about them with a clinician and do not have the tools to know what constitutes a reasonable price for care.
Medicine's unique ability to save lives is not exemption status from a cost-conscious culture. Just because medicine saves lives, it is not stamped "exempt" from having to think about costs. A good amount of health care is not emergency care, but rather preventive care and treatment of illness. Though health care may be a unique good in our society, the system should not be excused from having to consider sustainable models of spending. When the costs of health care are not transparent to both patients and clinicians, the temptation/decision to limit care may be hidden behind closed doors of obscure insurance policies. Other sectors of society save lives – police departments, prison systems, national security measures – and we still have to consider the costs of financing these services.
Good care is cost-conscious care. Was it worth it or should I buy it? We constantly, prospectively and retrospectively, evaluate how we spend our money: taking that vacation, buying a car, eating out. Was that a valuable use of our money compared to what we gained (pleasure/utility) and would we do it again? Though fewer choices may be available in some emergency situations or medically necessary circumstances where the decision process is accelerated or removed, we still can assess whether the care that we received is worth the cost. Have I been feeling better taking this medication? Has the pain subsided and is the out-of-pocket cost manageable? Has my health improved since seeing my doctor for "X"? These questions tumble around in our minds during our treatments and after in recovery.
Tools for clinicians and tools for health care costs. We are chipping away at this culture of unaccountable spending, of "running dad's credit card," when it comes to health care costs. But we aren't giving clinicians and people the tools they need to partner together to take on this dragon of costs. Partly because people and clinicians don't know how much health care services cost. Resources like Healthcare Blue Book are slowly becoming places where people can get estimates of how much their care will cost and insurance companies can give rough estimates prior to care. But these are outside of the exam room and can vary considerably. If we continue to make the standard of treatment a more expensive option when cheaper, equally effective alternatives exist, tools need to be developed for the clinical encounter, in the exam room, where the clinician and patient can participate in shared decision making by incorporating costs: "No, I don't want that medicine if it costs that much out of pocket," or "I'd rather try treatment 'X' if it will save me that much money."
Though having these conversations in the exam room may be a tall order for some, neglecting to include such an important issue is bad care. Sending someone home with a fancy procedure and large out-of-pocket costs may not have improved his health, but rather increased anxiety and stress over having to pay for his care. He may have chosen a different course of action had he known in advance the price he'd be paying for years to come. Likewise, prescribing a medication that a person will not pick up because it costs too much does nothing to help improve that individual's health.
We have a long way to go in delivering cost-conscious care that incorporates the patient's and the clinician's views. Evidence-based tools need to be developed for both the clinician and patient to be able to weigh the risks and benefits of a test, procedure or course of treatment, and conversations need to be started between clinician and patient about costs.
I want a cost-conscious clinician who is aware of what I'm being charged and in touch with the challenges I face in paying for my health care. I want to be part of system that acknowledges people's concerns with costs. People should demand from their clinicians this aspect of their care, and clinicians should demand from their health care organizations the tools to be able to deliver this information. Let's stop clinicians from passing the buck on the costs of care, and let's teach future and current clinicians to care about costs.
Patients already do.
This post originally appeared on Sarah's self-titled blog on July 15, 2013.