Tips for physicians who also need to be consumer advocates

For Lauren Oshman, MD, the patient’s financial condition was as much of a problem as his medical condition.

Her new patient had type 2 diabetes, for which he was being treated with canagliflozin (Invokana) and insulin glargine (Toujeo). His previous doctor had given him samples, but the manufacturers eventually stopped providing the freebies, so the doctor wrote him a prescription for the two drugs immediately before the patient came to see Oshman.

When he went to fill the prescriptions, the patient was shocked to find that the non-formulary drugs would cost him $700 a month, which he could not afford, even though they were covered under Medicare Part D.

And, just like that, the patient’s finances threatened Oshman’s ability to give him the care he needed. “Those are the days I go home steaming,” says the suburban Chicago primary care physician.

For her and many other primary care doctors, treating patients increasingly includes helping them find ways to afford the healthcare they need.

Whether a physician should take into account a patient’s financial condition when developing a treatment plan is a difficult question. What does it mean to consider whether a patient can afford healthcare? Should the doctor avoid certain treatments because of the cost? Should the doctor take steps to lower the cost of treatment, and, if so, what steps?

There is no doubt that high healthcare costs can hurt patient care. Patients struggling with debt might skip treatments or not fill prescriptions. In other instances, patients cut back on other necessities, such as food and housing, in order to afford care. 

“It’s ugly out there and it’s getting worse,” says George Ellis, MD, FACP, an internal medicine physician in Youngstown, Ohio, and chief medical adviser of Medical Economics. “I have patients tell me all the time ‘I can’t afford that drug.’ Patients are getting destroyed with these high deductibles.”

While the Affordable Care Act means more Americans have private health insurance, it doesn’t mean they can easily afford the costs. According to the 2015 Commonwealth Fund Health Care Affordability Index, 25% of privately insured working-age adults have high healthcare costs burdens relative to their incomes. It also found that 53% of privately insured people with low incomes have unaffordable health costs.

The Consumer Financial Protection Bureau estimates that half of all collection accounts on credit reports are due to medical debt, and many bankruptcies are linked to medical debt. A Kaiser Family Foundation study showed that deductibles rose eight times faster than wages in the past 10 years. 

High costs affect patients’ healthcare decisions, the Commonwealth Fund study found. Forty percent of adults with deductibles that amounted to 5% or more of income reported that because of their deductible they had not gone to the doctor when sick, did not get a preventive care test, skipped a recommended follow-up test, or did not get needed specialist care. Of adults with lower deductibles relative to their income, 21% said they did not get needed care because of their deductible.

Avoiding healthcare can harm patients immediately and in the future if problems get worse because they’re not treated. Minor problems become major and major ones can become life-threatening. Ellis notes that the laxatives prescribed for his recent colonoscopy cost $180. Add that cost to a procedure many patients are reluctant to undergo anyway and it only increases the likelihood that people will skip it. 

Considering care alone

Not all physicians feel a responsibility to consider their patients’ financial situation.

Greg Fihn, DO, a primary care physician in Las Vegas, is sympathetic when his patients complain about costs and he prescribes generics and shares drug makers’ coupons when he can, but doesn’t feel it’s his duty to go beyond that. He says he was never trained to take patient costs into account.

“There are things [patients[ could get done and treatments they could receive, but they can’t because of the cost,” he says. “Depending on the importance of the patient profile of care, I tell them this is important, they need to save up.”

Carrie Horwitch, MD, FACP, MPH, chairs the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee. The Seattle internist says the organization advocates judicious and appropriate use of medical resources while avoiding unnecessary expenses.

Horwitch says discussing patients’ ability to afford treatment should be part of informed decision-making, but warns against letting it become too great a factor. “Cost is always secondary, or even tertiary, to the overall care of the patient,” she says.

Ellis says he will do what he can to help patients but, in the end, “I am a physician. I will prescribe what I think helps you heal.”

Cost as a side effect

Others argue that prescribing treatment without taking into account its financial impact on patients is short-sighted and ignores a huge factor in determining whether a treatment will be effective.

Gary Seto, MD, a primary care physician in Pasadena, California, says he considers costs similar to a side effect of a drug or procedure. “I think it is part of any practice to find the best way to balance the cost of the treatment,” he says. “I try to frame everything as a cost-benefit solution.”

His methods include, when appropriate, ordering prescriptions in larger doses than necessary and telling patients to cut them in half, instructing patients how to look for low-cost pharmaceuticals and even sometimes recommending herbal supplements rather than prescription drugs, such as honey for a cough or ginger for menstrual cramps. “I’m not an alternative medicine doctor by any means, but when there is something available that has the same effect as medicine, I have no problems prescribing it,” he says.

Sometimes, doctors don’t take costs into account because they don’t know how expensive drugs and procedures are, says Samir Qamar, MD, a primary care practitioner in Las Vegas and founder of MedLion, a direct primary care model. Whenever he addresses a group of doctors, he asks them the cost of the last CT scan they ordered. Typically, no one knows, he says. 

MedLion lowers costs using methods as telemedicine and negotiated discounts for lab services. “There has to be a desire on the part of our physicians to help patients save money on healthcare costs,” Qamar says.   

Having the talk

How do physicians broach the potentially touchy subject of whether a patient can afford a drug, test or treatment?

Sometimes, they don’t have to. Physicians interviewed for this article said patients are increasingly likely to ask about costs and speak up if it’s more than they can afford.

Ellis says he often sees this at the urgent care center he owns in Youngstown. Many patients will argue the cost and demand discounts or free care, he says. “I can’t eat your deductible, I can’t eat your co-pay because it’s fraud,” he tells them. Some will leave without being treated rather than pay,

Often, they get angry. In a recent Medical Economics survey, 87% of respondents said they were encountering more angry patients, and financial issues such as copays and deductibles were cited as the greatest cause of patient unhappiness.

Some patients are reluctant to admit financial problems. Still others might not know they face a problem until they get the bill or fill a prescription. Many patients are unaware of healthcare costs or are unfamiliar with what their insurance covers. And those patients might decide they can’t afford treatment. “The doctor never finds out until the patient comes back and says they never filled the prescription,” says Qamar. 

Doctors shouldn’t assume insured patients can pay for care. Shrinking coverage and rising deductibles penses can put care out of reach for them, too. 

Lynne Lillie, MD, a primary care practitioner in Rochester, Minnesota, says she raises the question of affordability in the exam room.  “To be able to talk about the cost of care is very important,” she says. “There are folks who very much appreciate having their physicians consider the healthcare costs and take other factors into consideration.”

Sometimes, she says, the physician must talk a patient out of an unnecessary and expensive procedure they’ve requested. That can raise fears of withholding care or misperceptions of Obamacare.

It’s practically impossible, for physicians in multiple payer networks to know the details and costs for each patient’s plan. The best advice is to tell the patient to research their coverage and check with healthcare professionals to learnwhat’s covered.

Time is money

Actively trying to save patients money places another burden on already overtaxed doctors.

Oshman says it took her and her nurse about four hours on the phone to find her diabetic patient drugs he could afford, time for which she is not reimbursed. She described that case as a victory, but she’s had others where she’s been unable to help her patients get healthcare they can afford.

“You really need a team,” she says. “There is no way a primary care physician can see patients all day and do this kind of research as well. You only have so much energy.”

All of the work doesn’t need to be done by the doctor. Motivated patients can take steps to save themselves money without compromising care; sometimes, all it takes is for the physician to make them aware.

Some say the medical home model offers the best option for controlling costs because it eliminates redundancies, coordinates care and incorporates non-medical resources.

“It’s about the right care at the right place at the right time,” . “If we do this right, we’re going to see people save money.”