From Medscape Business of Medicine

The One Subject That Doctors and Patients Still Avoid

 

Gail Garfinkel Weiss, BBA, MSW

Posted: 05/04/2010

Introduction

Physicians talk with their patients about symptoms and health problems but they typically don't discuss the costs of different treatments or drugs. Yet some experts say that you need to have those discussions, because not having them could be harmful to your patients' health.

Richard M. Frankel, PhD, Professor of Medicine and Geriatrics and a senior research scientist at Indiana University School of Medicine, recalled when his father-in-law, a retiree on a limited income, remained hypertensive despite taking his blood pressure medication.

"He was taking the drug, but because the pills were expensive, he was cutting them in half, so the dose was under the therapeutic range," says Frankel.

Financial concerns are among several reasons why patients don't comply with treatment recommendations.

"As patients' out-of-pocket costs increase, physicians' decisions affect not only patients' medical well-being, but also their economic well-being," says internist G. Caleb Alexander, MD, a bioethicist who teaches at the University of Chicago's MacLean Center for Clinical Medical Ethics.

"In the case of prescription drugs, we know that 20%-30% of patients report cost-related nonadherence," Alexander adds. "As former Surgeon General C. Everett Koop famously pointed out, 'Drugs don't work in patients who don't take them.'"

Focus on Cost Is Growing

Drugs aren't the only area where price can have an impact on the patient's health. Concern regarding high out-of-pocket costs also affect patients' utilization of tests, treatments, and follow-up care. Indeed, in February the Wisconsin State Assembly passed the Health Care Transparency Bill, which requires healthcare providers to disclose, upon request, their median charges for a service, test, or procedure.

In signing the bill on March 10, the state's Governor, Jim Doyle, said, "Nowhere else are people asked to buy a product before they know what the price is. This bill is a practical step forward that will help people better understand what their healthcare costs are before making important healthcare decisions."

By bringing the subject of costs into the open, physicians can increase compliance and ease patients' economic burdens. "In many instances, doctors and patients can choose among different regimens," Alexander notes. "Some may be less costly, and patients would be more likely to adhere to them." For example, a patient might opt for a generic instead of a brand-name drug, or "watchful waiting" rather than radiation therapy for prostate cancer.

"Patients, on the other hand, may be reluctant to report cost burdens owing to embarrassment or concern that they'll get second-rate care if they mention economic troubles," he says. "And they may erroneously believe that physicians don't have any leeway in addressing these issues. Physicians, however, in addition to being pressed for time, aren't well trained for these discussions and often don't know what patients pay out of pocket for various treatments."

Doctors can turn this problem into an opportunity by using some effective techniques for broaching the topic and helping patients overcome financial worries that hinder optimal treatment.

Overcome the "Don't Ask, Don't Tell" Barrier

Because finance is such a sensitive topic, physicians and patients often avoid discussing it.

How can you bring the subject out of the closet? "An important step the physician can take is to normalize the issue," says Alexander.

"For example, when inquiring about nonadherence, I always begin by saying, 'Some patients aren't compliant with their therapies. About how often do you take your medicine?' Or, more specifically, 'Some patients are burdened by prescription costs, or by the costs of different tests or treatments. Are you not taking the medicine I prescribed last month because you're having trouble paying for it?'"

Frankel suggests asking about cost up front, when you make a therapeutic recommendation. For example, "Is this something that you can afford?" or "Is this something that is going to cause an economic problem for you?"

Of course, you need not bring up financial matters with every patient during every visit, but you can talk about costs in the following circumstances:

In determining which patients might not be able to follow your recommendations due to financial concerns, there's no substitute for conversing about these matters, especially when the stakes for the patient are high, says Alexander. "Many practices have signs that encourage patients to raise the money issue," he adds. "For example, 'If you're having trouble with your healthcare costs, please bring it to our attention.'"

"Physicians and patients discuss sensitive topics all the time," Alexander points out. "I don't view this as very different from a discussion of sexual practices or psychiatric symptoms. I think that most physicians are quite skilled and have substantial experience in helping patients to feel safe and comfortable and establishing a climate of trust where these discussions can take place."

Many physicians cite time constraints as a reason to avoid costs talks. But Frankel says that these conversations rarely take more than a few minutes and in the long run can save time.

"I'd rather know up front if somebody is going to have difficulty affording a treatment than to have to deal with the protracted consequence of a patient's noncompliance," he says.

Consider Alternative Treatments

"We operate in the real world," says internist Robert Wachter, MD, Associate Chairman of the Department of Medicine at the University of California, San Francisco. His blog, Wachter's World, focuses on healthcare quality and safety.

"It may be that I want the patient to run 3 miles a day but I know he won't or can't, so I come up with a treatment plan that I believe is realistic considering the facts on the ground." The same rule applies regarding costs, Wachter says. "My job as a physician is to understand patients' situations -- including their financial situations -- and then recommend what I think is the best care for them.

"If a patient says, 'Look, doctor, I can't afford the cost of the CT scan,' my job is to advocate for the patient. That means I might need to call the insurance company. If I'm unsuccessful, my next job is to come up with a more affordable alternative."

Eric. E. Shore, DO, JD, MBA, an internist and a health law attorney with Kane & Shore in Philadelphia, agrees. "Ordering the best treatment is worthless if the patient cannot afford it," he says.

"Assuming that a physician knows that treatment A is not covered, it becomes his or her responsibility to discuss treatment A, the reasons why it is best, and any covered alternatives with the patient. Sometimes, if treatment B, a covered service, is tried and proves ineffective, the insurance company may agree to cover treatment A."

It's vital to create a climate in which patients are comfortable being candid with you, because patient dishonesty affects physician decision-making, Shore adds. "If, for instance, a patient who is not responding to a medication as expected is reluctant to admit to splitting pills, the physician may decide that the dose is too low and order a higher dose, resulting in an overdose."

Sometimes an Honest Conversation Is Not Enough

"A hospital has social workers and a case manager on hand to address complicated topics, including what a patient's insurance will or won't allow, and many clinics employ someone whose job involves haggling with the insurance company," says Wachter.

In a large group practice, physicians can ask administrative staff to assist patients who are struggling with their out-of-pocket treatment costs. "Staff can play an important role in helping to identify resources that might enable patients to get financial assistance, more effectively engage with their insurers, or access safety net programs such as Medicaid or charity care," says Alexander.

However, in a solo or small group practice, physicians might have to call insurers directly to determine what options are available and advocate for patients when the insurer won't pay for a treatment. "It might be that the insurer doesn't understand the value of a certain treatment, so you need to explain it," says Wachter. "You may get the insurance company to approve your recommendations if you can make a case that not doing X today greatly increases the likelihood that the patient is going to develop a complication or will have to be admitted to the hospital."

In the case of drug treatments, if you're sufficiently persuasive you might be able to get the drug company to sell the medication at a lower cost, or even provide it free to the patient, says Shore.

Document a Patient's Noncompliance Due to Cost

If a patient can't afford treatment, that doesn't mean you're off the medical-legal hook.

When a patient avoids taking a medication or having a test because of the cost, be sure to record the entire episode in detail, says Shore. The note should describe your efforts to try to get the treatment covered, attempts to persuade a pharmaceutical company to supply a drug for free or at a reduced cost, your suggestions for less expensive alternatives (if there are any), and -- most important -- discussions with the patient about the potential consequences of not following your advice.

Be sure that the progress note includes your recommendations, why the patient declined to follow those recommendations, and that you gave her the opportunity to ask questions and answered all of her questions. Ask the patient to sign the note, Shore advises.

"Generally, such a note, even without the patient's signature, is sufficient to deflect any potential litigation," he says. "If litigation ensues anyway, it will be hard for a plaintiff's attorney to convince a jury that you were at fault when you did everything you could to ensure that the patient got the needed drug or treatment."

Shore has one additional piece of advice. "If your discussion with the patient is time-consuming, it's a good idea to specify start and end times in the note. Documentation indicating that you spent considerable time trying to persuade a recalcitrant patient goes a long way toward presenting a caring physician to a jury."

The new healthcare law is an important step in helping to reduce individuals' burden from medical costs, but it's not going to be a magic bullet. Encouraging patients to talk about cost burdens is also important.

Authors and Disclosures

Author(s)

Gail Garfinkel Weiss, BBA, MSW

Freelance writer, Merrick, New York

Disclosure: Gail Garfinkel Weiss, BBA, MSW, has disclosed no relevant financial relationships.

- From: http://www.medscape.com/viewarticle/720797_5 retrieved 5/12/10. Linked from “ Autism: Where We Stand on Recognition and Care”, Medscape Psychiatry, May 11, 2010.

 

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