“This is a discussion I have several times a day,” said Dr. Barbara Bumberry, a family medicine physician in Springfield, Mo. She now preemptively raises the cost issue when she writes prescriptions. Her patients increasingly ask about the costs of surgery and imaging tests as well.
But doctors warn that too much cost sensitivity among patients can compromise care if patients delay or skip needed treatment. And such conversations can sometimes raise uncomfortable issues for physicians about whether they are providing care in the most cost-effective way for their patients. Also, it is often difficult for doctors and patients alike to determine what patients' out-of-pocket costs will be. Those costs vary with each health plan, though some insurers such as Aetna tout that their websites feature cost calculators.
“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. He supports reducing financial barriers to care shown to improve health and raising cost-sharing for low-value care.
The percentage of Americans enrolled in employer-based plans with high deductibles has grown steadily in the past decade to comprise one-fifth of U.S. employees, according to the Kaiser Family Foundation. A 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, often paired with a health savings account.
Patients' concerns about out-of-pocket medical costs suggest that high cost-sharing plans have started to achieve policymakers' goal of making healthcare consumers more cost-conscious, potentially slowing the nation's medical spending growth. That's long been the approach favored by conservative policy analysts.
Greater cost-sharing has increased patients' interest in improving their diet and exercise habits, said Dr. Warren Licht, an assistant professor of medicine at the Hofstra North Shore-LIJ School of Medicine. “I am finally having conversations that I love to have with patients,” he said.
But patients' cost concerns also can hamper doctors' ability to make a diagnosis. To keep medical costs down, some patients referred for laboratory tests at the Scripps Coastal Medical Center in Carlsbad, Calif., decide which tests to delay, said Dr. Anthony Chong, the center's associate chief medical officer. For example, patients anxious about bills have asked him to delay echocardiograms to explore a heart murmur or tests for kidney damage from high blood pressure, he said. Some leave with a list of recommended diagnostic tests to comparison shop on prices. “I am sitting here waiting for the results to come back,” he said.
Doctors also face growing pressure to change their practice policies to reduce costs. Patients are asking to receive lab results, prescriptions and referrals without having to come in for a visit. “Many patients would much rather call the doctor to discuss an issue and then get a referral verbally,” said Licht, who will often agree with the request, even though he won't get paid for his time.
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.”
Some doctors say it's their responsibility to discuss costs with patients because their decisions and referrals can have a big financial impact on patients. But not all providers recognize that.
Larry Loonin, a retired college theater professor, said he 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. Since then, he grills his doctors on whether their referrals are in-network. He thinks doctors should be more cognizant of the patient's out-of-pocket costs. “They're just indifferent about it,” he said.