Health care spending

Is there anything about “SINGLE” we could like?

By M2|2017-10-08T11:15:04+00:00October 4th, 2017|Health care spending, Health Care Trends, Health Information Technology, Health Reform, Uncategorized|

Is there anything about “SINGLE” we could like?

As I write this, the latest version of Republican health reform has been halted. The Graham-Cassidy-Heller-Johnson bill (H.R.1628) was officially declared dead and next steps are all guesstimates.

It might be a coincidence that the bill was pulled and Senate Republican leadership decided not to bring the bill the floor for a vote just a day after CNN broadcast a debate between Sen. Bernie Sanders (D-VT), Sen. Amy Klobuchar (D-MN), Sen. Lindsay Graham (R-SC), and Sen. Bill Cassidy (R-LA) on “Obamacare”, CNN Debate Night: The Fight Over Obamacare; and a week after Sen. Sanders introduced the so-called “Medicare for All” bill on September 13.

More than once the CNN debate devolved into an argument over the Graham-Cassidy bill vs. “single payer” health care. But notably, two audience questions (one from a Republican and one from a Democrat) asked the Senate debaters to say what they would do immediately to lower the cost of premiums.

Usually the word “single” in health policy circles makes people think of “single payer.” In my opinion, there is not much possibility with the current Congress to pass a “single payer” bill that would create a nationalized health insurance and health provider system, but I do wonder if there is anything about the concept of “single” that could become policy. Here are two ideas: 1) A “single set of forms” and 2) A “single health IT system.”

“Single Set of Forms”

First, a single set of forms. Could Congress agree to pass a law that would require all insurers, payers, pharmacy benefit managers, etc. to use a standardized set of forms for everything from enrolling in a plan, to requesting a prior authorization for a prescription or medical procedure, to receiving a bill?

The concept isn’t new. Administrative simplification has been a buzzword off and on for more than a decade. Savings from reducing “billing and insurance-related” costs are substantial. A study in 2014 estimated, “A simplified financing system in the U.S. could result in cost savings exceeding $350 billion annually, nearly 15% of health care spending.”

Other studies have attempted to quantify exactly how health care providers waste administrative resources because of the multiple systems they must navigate in order to serve patients. For example, a typical physician might spend 3 to 4 hours per week interacting with health plans, other health care staff (e.g., RN/MA/LPN etc.) might spend 3 to 4 hours per physician per day, and clerical staff might spend 6 to 7 hours per physician per day interacting with health plans. Of the administrative activities involved, the majority of time spent is getting authorizations from health plans to perform services and navigating drug formularies.

A stark and oft-cited example is the Duke University hospital system that has three hospitals with 957 beds, but 1,600 billing clerks. Hard to think that a single set of forms – even if you have multiple payers – wouldn’t be a great way to save money in the U.S. health care system. Seems like “single” when it comes to “single set of forms” is an idea many people could support.

“Single” Health IT System

Second, a “single” health information technology (HIT) system might be a kind of “single” we could like in health care. Recently, the longtime CEO and president of the world-class health care delivery system Cleveland Clinic, Dr. Toby Cosgrove, appeared on Meet the Press Daily to discuss the Graham-Cassidy bill. Most of his comments were focused on ways to improve the current health care system, and one of his top ideas was to make health IT systems interoperable. He would certainly know.

A study from WestHealth Institute in 2013, The Value of Medical Device Interoperability, estimated more than $30 billion could be saved annually by making medical devices “talk to each other.” This seems obvious but the graphic below from WestHealth shows what is typical HIT in a hospital.

Sharing information from one device to another or between devices and the electronic health record (EHR) in a “consistent, predictable and reliable way” that allows clinicians to act upon the information would not only save money, it would also save lives and reduce negative outcomes. Lack of interoperability causes adverse events such as drug errors and diagnostics errors. Keep in mind that about 250,000 people die every year from medical errors. It also impedes clinicians’ abilities to prevent events such as pneumonia caused by ventilators put in at the hospital or postoperative shock.

Why does the word “single” in health care carry such negative connotations? Maybe because most parties—consumers, doctors, hospitals, and plans—don’t think a one-size-fits-all approach will work in this country to address such a wide set of needs when it comes to health care. But the downside to this stigmatization is that the word “single” has become so politically loaded that just uttering the phrase is often enough to stop a conversation that might otherwise turn into useful ideas for reforming our current health care system.

Maybe it’s time to focus on some good ideas for the word “single”—ideas that would truly benefit our large and diverse country. Administrative simplification and interoperability seem like a good place to start.

Opioid Epidemic and Drug Addiction Crisis Require Bold Action, but Also a Huge Amount of Money

By M2|2019-07-12T17:35:29+00:00August 9th, 2017|Health care spending, Uncategorized|

Opioid Epidemic and Drug Addiction Crisis Require Bold Action, but Also a Huge Amount of Money

On March 29, 2017, President Donald J. Trump signed an Executive Order establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis. The Commission is led by New Jersey Governor Chris Christie (R), and will issue a final report with its findings and recommendations by October 1, 2017.

The commission issued an interim report July 31, 2017, and many news headlines focused on either what the commission called “the first and most urgent recommendation,” which was to urge the President to declare a national emergency (which U.S. Health and Human Services Secretary Dr. Tom Price told reporters on August 8, 2017, the President has no plans to do immediately), or, some of the more alarming facts about drug addiction, for example:

“Only 10 percent of the nearly 21 million citizens with a substance use disorder (SUD) receive any type of specialty treatment.”
“With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks. (Emphasis in original).

In addition to some key findings, the interim report included areas for further consideration (to be included in the final report) and nine key recommendations, summarized as follows:

Declare a national emergency.
Rapidly increase treatment capacity.
Mandate prescriber education initiatives.
Immediately establish and fund a federal incentive to enhance access to Medication Assisted Treatment (MAT).
Improve access to naloxone.
Prioritize funding and manpower to quickly develop fentanyl detection sensors.
Enhance interstate data sharing among state-based prescription drug monitoring programs (PDMPs).
Ensure that information about SUDs be made available to medical professionals.
Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA).

The 10-page report includes a broad range of ideas, as it should, considering the process the commission used:

“In addition to conducting phone calls with Governors and their teams in all 50 states, we also held a listening session with bi-partisan members of Congress, and key cabinet members of your Administration. Individual Commission members have organized “listening sessions” and solicited recommendations from treatment providers, addiction psychiatrists and other physicians, data analysts, professional medical and treatment societies, medical educators, healthcare organizations, pharmacoepidemiologists, and insurance providers. Outreach also has been made to scientists with broad expertise in pain, addiction biology and treatment.”

“The first public meeting of the Commission was held on June 16th at the White House, and was a great success. The Commission members heard comprehensive public testimony by nine leading nonprofits, and have received more than 8,000 comments from the public, including comments from at least 50 organizations.”

It makes sense the commission was able to access so many voices of experience. There are lots of experts out there, and lots of previous recommendations, including one of the most recent, the 413-page Surgeon General’s Report on Alcohol, Drugs, and Health, Facing Addiction In America, published in 2016 under the Obama administration.

Show Me the Money

Ideas aren’t really the problem though. The real sticking point is money. How much money is needed to address what is likely a national emergency?

The Obama administration, the Trump administration, and our current Congress have all proposed some numbers.

The Obama administration’s President’s FY 2017 Budget included more than $1 billion over two years just for “expanding access to treatment for prescription drug abuse and heroin use.”

President Trump’s first budget, for FY 2018, proposed nearly $30 billion for drug control efforts, including for treatment and prevention efforts.

In the middle of negotiating Obamacare repeal and replace this summer, the Senate made changes to the Better Care Reconciliation Act that went from providing $2 billion to $45 billion over 10 years for substance abuse treatment and recovery.

And yet another estimate for caring for those who are already addicted was pegged at $183 billion over 10 years by Dr. Richard G. Frank, a Professor of Health Economics in at Harvard Medical School.

Addressing the opioid epidemic and drug addiction crisis can’t be about the politics of the Obama budget versus the Trump budget, or President Trump’s commission versus former President Obama’s Surgeon General’s Report on Alcohol, Drugs, and Health, Facing Addiction In America.

“If this scourge has not found you or your family yet, without bold action by everyone, it soon will,” exhorts the interim report.

We have plenty of ideas. We know what we need to do in order to save lives. But what we need to do won’t come cheap. The sooner we get to that conversation, the sooner we will be able to act boldly.

In Health Reform, Whose Costs Are We Talking About Anyway?

By M2|2017-10-08T11:38:04+00:00July 7th, 2017|Health care spending, Health Reform, Uncategorized|

In Health Reform, Whose Costs Are We Talking About Anyway?

Just in time for July 4^th weekend, the numbers were out. The Congressional Budget Office (CBO) estimates that if the Better Care Reconciliation Act were to become law, approximately 22 million people will lose health insurance coverage by 2026, (15 million will lose Medicaid and 7 million will lose nongroup coverage). Federal Medicaid spending would go down by $772 billion and spending to provide tax credits to help certain people buy health insurance (along with some other coverage provisions) would decrease by $408 billion (see chart below from the CBO).

Numerous articles have been written providing additional detail and commentary on what the bill’s changes would do to the costs of premiums in the Exchanges, and individual and small group market, as well as the effects on people with Medicaid, so that is not the focus of this piece.

Instead, we’d like to point out a little mentioned aspect of one change envisioned, which is the push from Medicaid to private insurance and what that would do to health care costs.

On Fox News Sunday, June 25, 2017, Dr. Tom Price, Secretary of the U.S. Department of Health and Human Services (HHS) explained to Brit Hume:

“So, what the Senate bill does is say, every single individual between zero between — up to 350 percent of the poverty level ought to be able to have some type of tax credit that will allow them to purchase the kind of coverage that they want. And it’s a tax credit, or refundable tax credit, or advanceable, so that nobody will fall through the cracks, nobody will have the rug pulled out from under them. We want a seamless transition for those that are moving from either Medicaid to the individual market or Medicaid to the employer-sponsored market, so that individuals are able to maintain the kind of coverage that they want for themselves.”

It makes sense that the Republicans are proposing such a solution. As Avik Roy wrote recently in an op-ed for The Washington Post, “For decades, free-market health-reform advocates have argued that the single best idea for improving U.S. health care is to maximize the number of Americans who can afford to buy health insurance for themselves, instead of having to depend on the government or their employer.”

He continues, “The Senate bill repeals Obamacare’s Medicaid expansion — an expansion that has trapped more than 12 million people in a program that researchers have shown has health outcomes no better than being uninsured. In its stead, the Senate bill offers low-income Americans robust tax credits to buy affordable private health insurance, just as those formerly enrolled in Obamacare’s exchanges will be able to.”

It is probably no coincidence that Dr. Tom Price, now Secretary of HHS, is helping design a system that encourages patients to move away from government insurance – especially since government programs pay physicians and other providers so much less than commercial payers.

Two recent studies from the Congressional Budget Office (CBO) highlighted the cost differential between Medicare and commercial payers for both physician services and hospitals. For physician services, CBO concluded what many of us in health policy know, but may be surprising to some:

“Commercial prices are (sometimes substantially) higher than Medicare fee-for-service (FFS)
Medicare Advantage prices are very close to Medicare fee-for-service (FFS)
Commercial prices vary substantially across areas and within areas; Medicare Advantage prices co-vary with Medicare fee-for-service (FFS)”

Here is another chart from the CBO for those of you who are so inclined:

For inpatient hospitals, the CBO conclusion was similar:

“The average commercial payment rate for a hospital admission in 2013 was about $21,400.
The average Medicare FFS rate for the same set of stays (in the same hospitals) was about $11,400.
On average, commercial rates were 89 percent higher than Medicare FFS rates.”

The reason this matters is because Medicaid rates are even lower than Medicare rates, often purposely so. Kaiser Family Foundation, based on data compiled by the Urban Institute, publishes The Medicaid-to-Medicare Fee Index which “measures each state’s physician fees relative to Medicare fees.” In 2014, the national average for all fee-for-service physician services was 0.66; for primary care physician services it was 0.59. In other words, on average, a physician gets paid by Medicaid 66% of what he or she gets paid by Medicare for the same service.

For some services, the Medicare and commercial rates are similar, for example, preventive and primary care visits (99213, 99214, and 99203 in the chart above). For other services, commercial rates paid to physicians are more like 200% of the Medicare rate, for example, breast biopsies (19081 in chart above).

Simply put, a service that earns a physician a reimbursement of $100 in Medicare, earns her or him only $59 in Medicaid. If that service is similarly reimbursed in a commercial plan, the physician earns about 70% more if the patient has commercial insurance instead of Medicaid.

For services that aren’t primary care, the differential is bigger. The physician who is reimbursed $66 in Medicaid, receives $100 in Medicare, but $200 in a commercial plan – so treating a patient with commercial insurance instead of Medicaid earns the physician three times as much in reimbursement.

Ensuring that “individuals are able to maintain the kind of coverage that they want for themselves” and making sure people aren’t dependent on government may be reasonable policy goals.

But let’s be more honest about whether this plan will actually mean we spend less on health care in the U.S.

What would it take to shop for health care the way we shop for cell phones?

By M2|2017-10-08T11:40:29+00:00June 14th, 2017|Health care spending, Out-of-pocket spending, Uncategorized|

What would it take to shop for health care the way we shop for cell phones?

The “vast majority” of Americans – 95% – now own a cell phone of some type, as the Pew Research Center noted earlier this year.

Shopping for a cell phone is a pretty ordinary experience. We compare prices and features, evaluating phones in terms of the newest, biggest, fastest or the least likely to break; we have preferences, and we shop based on those preferences.

However, this is not the way most of us shop for health care. Why is that? Partly because it’s difficult to get one of the most important pieces of information: price.

Notably, if you’re shopping based on quality, you can find at least some information on quality at sites like Health Grades – but price information is harder to come by.

More than half of states have laws requiring at least some health care entities to publish prices for at least some health care procedures. For example, Florida has a website allowing people to compare hospital rates. Patients in California can use a site that provides information on average prices for common inpatient procedures. In New Jersey, consumers can check quality and prices at hospitals.

What is still missing, though, is a patient’s ability to know his or her cost specifically.

However, some health care organizations are now realizing it can be a competitive advantage to provide more accurate information to patients about their cost-sharing.

For example, Integris Health System in Oklahoma City, OK has created a tool that provides about 240,000 price estimates for outpatient procedures per year, according to a recent PwC report. Price quotes are highly accurate, coming in at +/- 3-5% of the final charge. The tool steers patients to lower-cost providers that are still within Integris’ system, and the net result is that Integris went from $1 million in point-of-service collections in 2008 to $18 million in 2015.

In another example, St. Clair Hospital in Pittsburgh, PA noted an increase in high-deductible insurance plans among its patients. The hospital was “hearing from consumers about how important it is to them to know how much they will owe in advance of a procedure,” the report notes. After conducing listening sessions with former patients and their families, St. Clair created an online tool that provides estimates for 105 procedures. With the new tool, the hospital receives about 100 estimates each week, as opposed to the six they had been receiving previously.

What’s interesting about this tool is that rather than providing an estimate of the overall cost of a procedure, the St. Clair tool creates customized estimates, for example factoring in a patient’s insurance coverage. Thus, patients receive a true estimate of their particular out of pocket costs.

In yet another example, Geisinger Health System, Danville, PA, offers consumers price quotes, a one-stop web portal for patient information and a single, easy-to-understand hospital bill under its “Proven Experience” program, the report says. Furthermore, if a patient is not satisfied with their care, the system will refund a portion of the cost to the patient.

So what would it take to enable patients to shop for health care the way we shop for other goods and services? Fixing it on the supply side is one approach, as these examples show. Hospitals can use their ability to “be more retail” in order to win customers. The bottom line is: Patients need very specific information about what their particular costs will be. Fixing it on the demand side comes next. Patients need to demand more cost information is made available by their health plans and providers, and then they have to vote with their feet.

Light Health Care Users: Most Americans Use Few Health Care Resources and Have Low Out-of-Pocket Spending

By M2|2017-10-09T01:49:05+00:00May 23rd, 2017|Health care spending, Health Care Trends, Insurance, Out-of-pocket spending, Uncategorized, What do we pay for and why|

Light Health Care Users: Most Americans Use Few Health Care Resources and Have Low Out-of-Pocket Spending

Every day we read news coverage focused on rapidly rising health care costs, but a seldom-reported part of the story is how very few people are responsible for those costs.

A study of health care costs from 1977 to 2014 shows that over the length of the study period, the top 1 percent of the health care using population consistently cost the system more than the bottom 75 percent. Just 1 percent of the population, in fact, accounts for nearly a third of medical spending.

The study, published in the April 2017 issue of Health Affairs, finds that “most Americans use few health care resources and have low out-of-pocket spending.”

In addition, more than 93 percent of these light spenders (those in the bottom half of the population) believe they have received “all needed care in a timely manner,” and the light spending by the majority of the population “has remained almost unchanged during the thirty-seven-year period.”

This light spending has also remained “unchanged since the inception of the Affordable Care Act (ACA),” as a Medscape article on the study notes.

These findings matter because most health care policy discussions focus on spending at the population level – in other words, on the 1 to 5% of the U.S. population that incurs significant medical costs. That isn’t how individuals think of health spending, however. Most of us think of what we as individuals, or perhaps our family, spends on health care.

Insurance, by design, must include many non-users, so to speak, in order to work. Most of us buy home insurance or car insurance and never use it. That is, we make payments to an insurer in the form of premiums, but we typically don’t have car accidents and don’t have house break-ins or fires. Similarly, most people don’t have much in the way of medical spending.

But if too many light spenders don’t buy insurance, the price of insurance increases for everyone. And in fact, that is what happens.

This chart from the April 2017 Health Affairs article shows that the highest spenders are the most likely to be on public insurance – think Medicaid for the severely disabled – and light spenders are the most likely to be uninsured – they don’t think they need it, and they probably don’t for years and years – until something catastrophic happens.

In terms of out-of-pocket spending, for light spenders in 2014 this figure was just $75 on average, which is less than the $94 (in adjusted 2014 dollars) spent in 1977, the authors find. On the other hand, high spenders averaged $1,096 in out-of-pocket costs. And 50% of light spenders had no spending at all (not including health insurance premiums, if they were insured), whereas only 6.1% of high spenders had none.

As we continue to think about how to improve or change health care insurance, delivery, and payment in the U.S., it is important to remember how few people actually interact with the health care system every year. Even for people buying health insurance, a large proportion of people spend little on actual health care services, and that has remained stable for decades.

This makes some complaints about the Affordable Care Act a little easier to understand. As the study explains, light spenders “as a group are unlikely to receive substantial short term benefits from the Affordable Care Act.”

The question is, what is insurance for? We probably shouldn’t design the entire U.S. health care system for people who don’t need care. But the subtle lines of who pays more, the sick or the well, the old or the young, are something we still need to work out.

Who Deserves Health Care? (a.k.a. Health Care is Hard)

By M2|2017-10-09T01:51:07+00:00May 17th, 2017|Health care spending, Insurance, Uncategorized|

Who Deserves Health Care? (a.k.a. Health Care is Hard)

Congressional efforts to repeal (and replace?) Obamacare seem to be on track to continue over the summer. The American Health Care Act (AHCA) passed the House May 4, 2017, and as written will gut Medicaid, defund Planned Parenthood for one year, and allow health plans to charge older, poorer people way more than they are paying now for health insurance.

You can read all sorts of news and opinions about why the House-passed AHCA bill is problematic if the goal of the bill was either to reduce health care costs for consumers or ensure access to health insurance coverage. But you might not read this: Late in February President Trump said health care is unbelievably complex – he was right and this is why.

Health care comes down to two questions that are easy to ask, but hard to answer. First, who deserves health care? Second, who should pay for it?

Question 1: Who deserves health care?

If you think everyone deserves health care, great. Then you can just jump ahead to the second question. However, to understand the current health care debate, it is important to know that many people, including many elected officials, think only certain people deserve health care. And when they say health care, they mean health care insurance.

For those promoting a “free market” approach, they support a system in which a person who “works hard” is rewarded with health insurance coverage. That is how most people in the U.S. get health insurance now. The problem is the definition of “works hard.” In 2014, 83% of people with a full-time job who made more than about $48,000 per year (400% of the federal poverty level or FPL) were offered insurance by their employer (see chart from Kaiser Family Foundation).

So one definition of “works hard” to the proponents of “let the free market decide” is well-paid full-time workers. Indeed, employer-sponsored insurance is the basic building block of the U.S. health care system. Historians will explain that in 1940 about 9 percent of the population had health insurance. In 1943, the Internal Revenue Service (IRS) ruled an employer offering the fringe benefit of health insurance could do so tax-free. As a result, in 1953, health plan participation jumped to nearly 65% of people. The IRS giving certain kinds of health insurance tax-free status hardly seems to be “letting the free market decide,” but we digress…

Besides full-time employees, who else worked “hard” enough to deserve health insurance? The second biggest group are Medicare enrollees. About 15% of Americans receive Medicare. But again, they “deserve” it, because every worker in the U.S. pays a portion of his or her paycheck to the Medicare fund. A person receives Medicare because they earned it – he or she either worked a certain number of years during their lifetime and paid into the fund, or their spouse did.

Yes, health insurance is different from health care. Emergency rooms are required by federal law to accept emergency patients. And community health clinics provide care on a sliding scale. So technically, everyone can get health care because we have emergency rooms and free health clinics.

Question 2: Who should pay for health care?

Even if your answer to question 2 is, “We should all pay!” it doesn’t necessarily make the mechanics of everyone paying any easier. If everyone pays, how do we do it? A flat tax for every person? A tax based on income? A tax based on how much health care costs where you live?

Should sick people pay more than people who are well? Should older people pay more than younger people? Should we all pay for a basic set of benefits, even those we don’t use? For example, should men have to pay for maternity care? Should young people have to pay for prostate exams or colonoscopies? Should middle-aged people have to pay for childhood vaccines?

As mentioned previously, we all pay for health care in the system we have today because our taxes go to support free health clinics and to cover the costs of hospitals who provide emergency care that is “uncompensated.”

Which brings us to why health care is so unbelievably complex. Each of us has our own experience with the system, and whatever we don’t like, we blame on “the system.” If your premiums have gone up in the past few years, you might blame Obamacare, but it is just as likely that your employer changed your health insurance plan so they could save some money for their shareholders. On the other hand, if you couldn’t get insurance before Obamacare because you had a pre-existing condition, you might credit Obamacare for that access.

One individual’s experience of health care or health insurance is not everyone’s experience, and your experience may or may not be because of Obamacare. But every story counts. Many elected officials are hearing from constituents that Obamacare is failing them, and that may very well be true. Other constituents are saying Obamacare saved their life, and that may also be true. Having an honest conversation about all the ways Obamacare helps and hurts people, and who deserves what, would be a better way to get to policies that would work. But that would be hard.

Physicians Missing Opportunities for Communication to Help Patients Reduce Costs, Duke Study Finds

By M2|2017-10-09T01:53:50+00:00May 3rd, 2017|Health care spending, Uncategorized|

Physicians Missing Opportunities for Communication to Help Patients Reduce Costs, Duke Study Finds

Health care providers have an important role in helping patients navigate the restrictions health plans put in place that may drive high out-of-pocket expenses. Clinicians could help patients determine whether lower price interventions might work, for example.

To help patients make health care choices that are informed by knowledge of expected costs, some experts have recommended routine physician-patient communication about out-of-pocket expenses.

However, “there is very little research assessing how often, or how well, doctors and patients discuss health care costs during clinical encounters,” Peter Ubell, Duke University, et al., note in a study published in Health Affairs.

To address this gap, the authors studied audio recorded clinical encounters, and found that “physician-patient spending conversations did not always enable patients to successfully navigate out-of-pocket expenses.”

In fact, some physician behaviors “stand in the way of helping patients make informed decisions about ways to potentially lower their out-of-pocket spending,” the authors find.

Indeed, as noted below, the authors identified a range of physician behaviors representing “missed opportunities” to address patients’ cost concerns, from dismissal of such concerns, to physicians being too quick to accept patient’s dismissals of their own concerns (for examples of actual physician/ patient conversations demonstrating some of these missed opportunities, see accompanying chart below).

Researchers reviewed 3,000 physician-patient interactions for management of breast cancer, depression, and rheumatoid arthritis.

Two broad categories of physician behaviors led to “missed opportunities to reduce out-of-pocket expenses”-

Missed opportunities to address patient’s financial concerns – For example:

Failure to recognize potential financial concern: “For patients to productively discuss out-of-pocket spending with their physicians, they need physicians to recognize that they have financial concerns. However, patients do not always state their financial concerns explicitly,” the authors say.
Distracted from patient’s financial concerns by frustration with the system: “When physicians discuss health care expenses with patients, they sometimes spend considerable time complaining about the systemic factors contributing to high out-of-pocket spending. Occasionally, voicing those frustrations seems to distract them from exploring how to reduce patients’ expenses.”
Dismissal of patient’s financial concerns: “Even when physicians pick up on and acknowledge patients’ financial concerns, they sometimes dismiss such concerns before exploring whether it is possible to reduce patients’ financial burden. For example, in one interaction, a patient explained that ‘[I] cannot take my pills, because there is now a copay.’ She mentioned that she had ‘zero income,’ to which the physician replied, ‘That’s what happens, yeah,’ without addressing her inability to pay for her medications.”
Hasty acceptance of patients’ dismissal of financial concerns: “Sometimes, patients express financial concerns to physicians, and then they, the patients, dismiss those same concerns. When physicians readily accept such dismissals, they miss out on opportunities to find out whether such concerns are legitimate.”

Limited resolution of patient’s financial concerns – For example:

Assuming “coverage” means full coverage: “Many insurance plans do not fully cover services but leave patients with copayments or coinsurance,” the authors note. “When physicians mistakenly assume that ‘coverage’ means full coverage, they might unwittingly expose patients to burdensome out-of-pocket spending.”
Assuming generic medications are affordable: “In recent years, consolidation among manufacturers has led to significant increases in the price of some generic medications,” the authors note. “Even absent such price increases, the cost of generic medications can burden those patients who are stressed to their financial limit. But physicians do not always recognize that ‘inexpensive’ generics can be unaffordable for their patients.”
Assuming copayment assistance programs and coupons resolve financial concerns: “Sometimes pharmaceutical companies create programs to help patients pay for expensive medications. These programs do not always eliminate all out-of-pocket expenses. And not all patients who seek such assistance receive it.”
Temporizing financial burden without discussion long-term solutions: “Sometimes physicians make earnest efforts to address patients’ financial concerns but focus on temporary solutions without discussing steps necessary to yield long-term financial relief. Physicians offer free samples of medications to treat patients’ problems even when such samples only delay the day when patients will face significant expenses. In some cases, in fact, the free samples are expensive drugs, and use of the free samples might distract physicians from trying less expensive alternatives first. Other times, physicians turn to short-lived drug discount cards or coupons,” the authors say.

“Many physicians want to help relieve patients of their financial burdens, to increase the likelihood that they will receive prescribed interventions and improve their overall quality of life. To achieve this goal, physicians need to recognize when their own behaviors interfere with these efforts,” Ubell, et al., say.

“For example, when patients are burdened by the expense of prescribed interventions, physicians should consider whether there are less expensive alternatives. When the best solutions are short in duration, it behooves physicians to make plans to find longer-term solutions. And when patients raise and then dismiss financial concerns, physicians should take a moment to assess whether such dismissals are warranted.”

“Many health care policies are ultimately played out ‘at the bedside,’ by influencing the way doctors and patients make medical decisions,” the authors say. “In the case of policies promoting health care consumerism, many patients are faced with important decisions about whether the benefits of health care interventions justify their financial cost.”

As this study demonstrates, patients often are ill-equipped to make medical decisions and may require additional information to do so. One way to address this issue may be to offer additional training for physicians, in order to help facilitate the conversations with patients about their financial concerns. Alternatively, physicians could consider adding a staff member who could be a resource for answering financial questions from patients.

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