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Reform Update: Patients' cost sensitivity worries some doctors


By Melanie Evans
Posted: August 13, 2014 - 4:30 pm ET
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Doctors who are more accustomed to fielding patient questions about the benefits of procedures, tests, drugs and specialist referrals say patients increasingly are demanding answers to two additional questions: How much will it cost and do I really need it?

Those questions and others like it—such as “Can it wait?”—have grown more frequent as more patients bear financial responsibility for more of their medical bills. That's because a growing number of health plans have high deductibles that can exceed $5,000, high coinsurance rates, and limited or no coverage when patients seek care outside the plans' narrow provider networks.

Some physicians say they welcome conversations with patients prompted by high-deductible plans about efforts to prevent illness, minimize complications and avoid unnecessary care. Frank discussion of cost also can help patients avoid the stress and financial damage of large medical bills. “It matters because the way healthcare pricing works in the United States, you can go in for completely routine care and it can hit your deductible in a big way,” said Dr. Neel Shah, a physician and founder of the not-for-profit Costs of Care, which works to reduce patient bills.

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But doctors also warn that too much cost sensitivity among patients can compromise their ability to do their job, with potential harmful consequences if patients delay or skip necessary treatment. And these conversations sometimes can raise uncomfortable financial issues for doctors about whether they are providing care in the most cost-effective way for their patients.

“This whole system makes no sense at all… that cost sharing is going up across the board in a one-size-fits all fashion,” said Dr. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design. “As we make people pay more for something they buy less of it.” That includes necessary medical care. He recommends that health plans reduce or eliminate financial barriers to care that is proven to improve patients' health and raise financial barriers to care that has little value.

Under Obamacare's exchange plans and newer employer-based plans, the percentage of Americans enrolled in employer-based plans with high cost-sharing has grown steadily in the last decade to one-fifth of employees. Narrow network plans, which require patients to spend more on care outside of a network, have proliferated under the healthcare reform law, in the employer market, and in Medicare Advantage. A new survey by the National Business Group on Health found that next year 32% of companies intend to offer only a high-deductible, “consumer-directed” plan to their workers, often paired with a health savings account.

Patients' increasingly vocal concerns about their out-of-pocket medical costs suggests that these high-deductible/high coinsurance plans have started to achieve policymakers' goal of making healthcare consumers more cost-conscious and potentially slowing the nation's medical spending growth. That's long been the approach favored by conservative policy analysts.

But patient concerns about cost can delay or limit doctors' ability to make a diagnosis. In Springfield, Mo., primary care physician Dr. Barbara Bumberry said patients increasingly ask her about the cost of operations or diagnostic imaging and whether they can be delayed. She tries to accommodate the request when patients' symptoms aren't too severe. She may also recommend an alternative test that is less expensive but also less effective. She may not get all the information she would like from the lower-cost, more limited tests.

Some patients referred to the diagnostic laboratory at the Scripps Costal Medical Center now choose which tests to complete and which to delay to keep their medical bill down, said Dr. Anthony Chong, the center's associate chief medical officer. Patients who are anxious about bills have asked him to delay an echocardiogram to explore a heart murmur and tests for kidney damage from high blood pressure, he said. Others leave his office with a list of recommended diagnostic tests so they can comparison shop on prices, leaving Chong wondering if they'll follow through. “I am sitting here waiting for the results to come back,” he said.

On the other hand, doctors increasingly may face pressure to change their practice policies to reduce the cost burden for patients facing higher out-of-pockets. Sabrina Corlette, project director at Georgetown University's Center on Health Insurance Reforms, said she recently argued with her doctor about whether she needed to go in for an exam to have a prescription refilled. “Ultimately I gave in and went in for the appointment because she made it clear she wouldn't renew my prescription without that exam,” Corlette said. “But I was pretty steamed about it, especially since I don't believe there's any medical evidence to support her requirement.

Patients' financial concerns are warranted. Distress from medical debt is significant and can undermine their personal finances for years. Household medical bills pushed 10 million people into poverty in 2012, according to Census Bureau figures released last November. Roughly half of unpaid bills sent to collections are medical-debt related, according to credit score company FICO.

One study of 1,500 breast cancer patients found one in 10 women continued to struggle with medical debt four years after treatment. About 20% of women spent at least $2,000 and up to $5,000 on medical bills that insurance would not cover. For another 10% of these women, bills ran as high as $10,000. Women used credit cards and borrowed from friends, families or against their house to pay the bills, researchers reported in March in the Journal of Clinical Oncology.

Doctors said it's their responsibility to bring up the issue of cost. “We are replacing a physical ailment with a financial strain,” said Dr. Christopher Moriates, a hospitalist and assistant professor with the University of California San Francisco.

Larry Loonin, a retired college theater professor, agrees. Loonin switched dermatologists after his doctor referred him for treatment outside of his Medicare Advantage plan's network and used an out-of-network laboratory for a biopsy. He owed more than $400 as a result and has since grilled his doctors on whether their referrals are in-network to avoid the unexpected expense. Loonin thinks doctors should be more cognizant of cost and the potential financial strain on patients. “They're just indifferent about it,” he said. “They owe it to patients to say something about it.”

But doctors and patients encounter difficulties in figuring out what patients' out-of-pocket costs will be, creating obstacles to reaching an informed decision. The cost to patients varies with each health plan, though some insurers like Aetna tout their websites featuring cost calculators.

“Honestly, it doesn't make the conversation easy," said Dr. Hank Capps, a family physician with Novant Health and chief medical information officer for the system's medical group. “It's not like we can tell them how much it will be.”

Ultimately, patients must decide whether they need the care regardless of cost. Doctors say they can only help inform the decision. “I don't like telling the patient what to do,” said Dr. Warren Licht, an assistant professor of medicine at the Hofstra NorthShore-LIJ School of Medicine. “It's their money. It's their health. I just give them the facts.”

Some make choices that doctors disagree with. “Doctors in that context don't get bent out of shape if a patient says I don't want to do something,” Capps said. “I think doctors turn around and say here's the risk of not doing it.”

(Managing Editor Harris Meyer contributed to this article.)


Will states become more aggressive consumers?

Reference pricing under the Affordable Care Act earned a small but notable mention in the latest snapshot of health benefits for state employees from the Pew Charitable Trusts and John D. and Catherine T. MacArthur Foundation. Reference pricing, which caps what insurers will reimburse for certain procedures to limit spending, was listed among strategies to reduce costs in a newly published report (PDF). “States generally have little direct control over price differences among providers within their market,” the report said. The states spent $30.8 billion on health benefits for 2.5 million individuals. But the 2011 use of reference prices for hips and knees by the California Public Employees Retirement System appeared to prompt some hospitals to lower prices. The report noted that the Obama administration endorsed reference prices as compliant with the ACA earlier this year.

The tipping point?

Not-for-profit health systems and hospitals face ongoing challenges as healthcare reform alters how providers are paid, Standard & Poor's analysts said as they announced new snapshots of the sector's financial performance. "We believe the sector is at a tipping point where negative forces have started to outweigh many providers' ability to implement sufficient countermeasures," said S&P credit analyst Margaret McNamara in a news release. The median operating margins for health systems rated by Standard & Poor's dropped to 2.2% from 2.9% the prior year. But the ACA outlook for systems isn't all bleak. “One bright spot may be what we believe is a near-to-medium-term spike in volume from Medicaid expansion and exchange patients. Under the Affordable Care Act, providers could see a drop in charity care and bad debt expenses, although there may be some offsetting increases from patients unable to afford high deductibles and copayments associated with their new insurance coverage,” the report said.

Follow Melanie Evans on Twitter: @MHmevans


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