Why doctors must discuss costly treatment before patients receive bills

A $1,000 bill for a $30 Pap smear test. A $55,000 bill for out-of-pocket costs for breast cancer treatments. A patient who loses her home because of astronomical medical expenses. All true accounts of the reality facing patients and all because physicians failed to discuss the costs of test and therapies with patients before they ordered them.

Physicians need to consider out-of-pocket costs as a "side effect" to treatment when they make decisions about their patients care, according to one of two perspectives published Thursday in the New England Journal of Medicine. The two perspectives illustrate why it is imperative that physicians discuss costs with their patients and understand the role they can play in helping rein in escalating healthcare costs

Healthcare providers don't often discuss potential costs before ordering diagnostic tests or making treatment decisions. As a result, patients may unknowingly face "daunting and potentially avoidable healthcare bills," wrote lead author Peter A. Ubel, M.D., professor of business administration and medicine and public policy at Duke University in Durham, N.C., in the first perspective.

Treatments are often "financially toxic" and can harm a patient's well-being, he wrote. Therefore, he said physicians must disclose the financial consequences of treatment alternatives just as they discuss treatment side effects with patients.

"In our research, we discovered that many insured patients burdened by high out-of-pocket costs from cancer treatment reduce their spending on food and clothing to make ends meet or reduce the frequency with which they take prescribed medications," Ubel wrote.

In the second perspective, Cheryl Bettigole, M.D., M.P.H., a family physician and the chief medical officer of Complete Care Health Network in southern New Jersey, wrote how she became increasingly alarmed that her female patients were skipping health screenings because of skyrocketing costs. The reason, in many cases, is that physicians, nurse practitioners and medical assistants are checking off boxes on an order form for multiple high-screening tests that are unnecessary.

"Costly tests that once would have required physicians to submit multiple collection vials and specimens can now be ordered with the Pap smear simply by clicking a single box in the electronic medical record," she wrote."Nothing at any point along the way alerts either the clinician or the patient to the high costs of these tests or to the fact that there is little medical evidence to suggest that they are useful for most patients. It seems harmless, even possibly beneficial, to run these additional tests, and for our staff, it eliminates the risk of missing a test the doctor might have wanted to have run."

The risk, she said, is more women may choose not to undergo screening, afraid of the financial consequences.

"It is becoming increasingly clear that physicians have an obligation to be good stewards of limited resources and to understand the financial effects that the orders we write have on our patients," Bettigole wrote. "We need to teach medical students and residents to see this as an important aspect of their responsibility to their patients."

For more:
- read Ubel's piece
- here's Bettingole's perspective

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