Cost of care, considered

When considering the best course of treatment for a patient, doctors have long assessed medical metrics for gauging effectiveness. But when physicians look after their patients’ best interests, couldn’t financial well-being have a place, too?

After all, medical bills are the leading cause of personal bankruptcy filings, according to the analysis site NerdWallet, and health expenses cripple the finances of 1 in 5 American adults.

As a result, some major physician associations now want to insert cost as a consideration.

For instance, the American Society of Clinical Oncology recently established a task force that the organization of cancer doctors says will “determine the relative value of drugs” by considering “efficacy, side effects and price.” Meanwhile, the American College of Cardiology also intends to factor in expense when ranking treatments for heart conditions.

The notion has generated controversy. The New York Times notes that such guidelines “could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment—at the end of life, for example—is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.”

However, as the Times also points out, guidelines are voluntary. Doctors have latitude in making their decision.

“It’s important for me to think about the economics of prescriptions and tests that I’m ordering because it’s important to my patients,” said Dr. Marcia Nelson, a family practice physician at Mission Ranch Primary Care in Chico. “It’s no use to anybody to prescribe a medication that a patient won’t be able to fill because it’s too expensive for them; it does my patients a disservice.”

She takes the same approach to diagnostic procedures, though those involve another layer of deliberation.

“Sometimes people come in thinking they want a certain kind of test done and I know their insurance won’t cover it,” she said, “and I know it’s appropriate to go through these other treatments and investigations [first]. It may be inappropriate to jump to the most expensive test right out of the gate.”

Cost consciousness isn’t new—Dr. Marcia Moore, a Chico cardiologist, says that “it’s been a part of the process for almost two decades.” She has patients, particularly those too young to qualify for Medicare, with no insurance, so once they get past their emergency condition, her office needs to “shepherd” them through the particulars for follow-up care.

Dr. Roy Bishop, the family medicine physician who runs Argyll Medical Group in Chico, notes that this degree of effort can tax a doctor’s office, particularly a primary care practice that sees hundreds of patients a day. As a result, patients share some of the burden.

“Getting health care is not a passive activity,” Bishop said. “We give the patient homework; we ask them to find out what is covered or where they can find a particular specialist. Quite often, to be honest, in primary care we do not have the staff to handle patients and do this [fact-finding as well].”

Of patients’ reaction, Bishop noted: “Most of them are so shell-shocked and worn out by the changes in health care that they accept with resignation that they have to do it.”

Complicating the doctors’ thought process—and their patients’ quest for information—is the sheer number of insurance plans. While a medical practice might work with just a handful of insurers, every insurer offers a variety of policies, each covering different medicines and procedures, with different co-pays.

On top of that, insurers are prone to changing their formularies (the prescription drugs they cover) as well as approval processes.

How can doctors keep it all straight?

They can’t. Computer systems help, but in the absence of a centralized clearinghouse for insurance plans, physicians rely on past experience and patient feedback.

For prescriptions, Nelson finds that drugs with generic options generally tend to be covered by patients’ insurance, with low co-pays. However, she added, “if they go pick up the medication and the cost is out of line with what they can afford, I encourage them to let me know and I’ll see if I can find an alternative for them.”

When it comes to tests, Nelson says she tends to order from a common battery, based on the array of illnesses and injuries she encounters frequently. Moore, as a specialist, says she is in a better position than a general practitioner to know specific costs, but even she gets surprised.

In any case, Bishop said, the onus is ultimately on the patient.

“I’m a professional adviser,” he said. “I don’t sell anything to patients other than my time and advice. If your adviser suggests you do something, either do it or do further research.”

In that regard, the medical staff at Enloe Medical Center has embraced Choosing Wisely (www.choosingwisely.org), a set of recommendations from physician academies. Nelson, Enloe’s vice president for medical affairs, said these discussion points also translate to hospital care.

“This isn’t making an economic decision; it’s making an evidence-based decision about what medical care is best,” Nelson said. “It’s important to recognize that providing efficient care—giving care that’s mindful of the cost and resources spent—is good medical care.

“It doesn’t mean you’re denying patients; it means you’re having your thinking cap on with every decision you’re making.”