Reform Update: Docs urged to consider patients' financial stress

Doctors should talk to patients about their financial concerns relating to their medical care with questions such as, “Are you worried about how your medical care will be paid for?” And they should discuss treatment options and costs with patients. To avoid treating patients differently based on income, all patients should be screen for financial stress. Doctors should be prepared to help patients identify financial resources when payment is an issue.

Those are recommendations in a commentary in the Journal of the American Medical Association, which notes that household financial strain from medical bills won't disappear even after millions of uninsured and underinsured Americans gain insurance coverage next year under the Patient Protection and Affordable Care Act. The authors urged physicians to consider cost as one factor that can negatively affect patients' health and well-being.

“Medical bills are now a leading cause of financial harm and physicians decide what goes on the bill,” wrote the physician-authors. Doctors can alleviate unnecessary financial strain by paying close attention to the cost of their own treatment recommendations, said Dr. Christopher Moriates, Dr. Neel Shah and Dr. Veneet Arora.

Expanded insurance coverage for the uninsured “doesn't make them immune to healthcare costs,” said Moriates, an assistant clinical professor at the University of California, San Francisco, a hospitalist.

Indeed, health insurance that requires patients to pay high deductibles or a percentage of their medical bills are increasing in the private market. And high-deductible, high-cost sharing plans, which typically have a lower premium, may prove attractive to low-income, uninsured households that areexpected to gain coverage in plans they buy in the new state insurance exchanges.

About 9 million Americans are expected to buy commercial insurance this year sold in new markets created by the Affordable Care Act. That number is projected to grow to 25 million by 2022. New ACA rules (PDF) set limits on how much households must pay each year, but it's not a small amount: $6,350 for individuals and $12,700 for families (though people who earn less than 250% of the federal poverty level are eligible for subsidies to limit their out-of-pocket costs). An early look at copays and deductibles in the new insurance exchanges show the amounts are rising.

Moriates said the financial consequences of treatment choices should give doctors another reason to review the evidence for which therapies are appropriate. The authors cited Choosing Wisely, a campaign by the ABIM Foundation, Choosing Wisely, to raise awareness of therapies and screening that have been identified by physicians as overused. (All three authors disclosed grants from the ABIM Foundation.)

The authors also acknowledged money may be an uncomfortable subject. But that is not uncommon in medicine, they wrote, noting “physicians already participate in difficult discussions with patients about opiate abuse, domestic violence and end-of-life decisions.”

Contrary to expectations, state-run insurance exchanges in 15 states plus the District of Columbia plan to offer employees of small businesses multiple health plan options in their Small Business Health Options exchanges, according to a report commissioned by the Commonwealth Fund. Even though the Obama administration delayed requiring the multiple-choice option in state exchanges, most of the 17 states running their own are going ahead with the feature, which small business groups say would make the SHOP exchange more appealing. Under the multiple-option feature, business owners participating in the SHOP exchange could pay a defined amount for coverage of each worker, and each worker could pick their own plan using that money. They would pay the difference out of pocket for a more expensive plan. A spokeswoman for the Blue Cross and Blue Shield Association, which favors a delay in the multiple-choice option, told Kaiser Health News the association was surprised the states, including California, New York, Minnesota and Oregon, were moving forward with it.

The Internal Revenue Service in coming months will finalize the criteria under which not-for-profit hospitals could lose their tax breaks for violating the healthcare reform law's rules on billing and collections. Public comment on IRS enforcement proposals closed on July 5 with calls from the American Hospital Association and Catholic Health Association for more clarity on “egregious” violations of the ACA's billing, collections, financial aid and community needs assessment provisions for tax-exempt hospitals. Roughly 60% of U.S. hospitals are tax-exempt.

Insurance design may improve quality, but that may not deliver immediate savings, said researchers who looked at the use of value-based insurance design and prescription drugs. A review of 13 published research studies on value-based benefit design found that payers did not see savings in overall healthcare costs when patients did a better job filling their prescriptions. The review, published in Health Affairs, found that patients responded favorably to lower out-of-pocket costs for drugs. The value approach to benefit design, which uses incentives to encourage efficient use of healthcare and healthy behavior, got an encouraging mention in the Patient Protection and Affordable Care Act, the review authors noted. Follow Melanie Evans on Twitter: @MHmevans