'We'll Need an MRI on Your Wallet'

A female patient sits on hospital bed. credit: Matthieu Spohn/ès/Corbis Matthieu Spohn/Corbis

How much bad news is your doctor obliged to give you?

Consider this very depressing scenario: You've got colon cancer. Your doctor might tell you there's some good news, that there's a powerful and effective drug called Avastin, but warn you about its potentially harmful side effects - it can mess up your heart. But should your doctor also mention another devastating side-effect - that an Avastin regimen could cost more than $50,000, and that a patient who has Medicare but no supplemental insurance might have to pony up $9,000 for this treatment?

We like to pretend doctors are purists who only focus on our physical and mental well-being, but isn't the health of your wallet also important?

In light of the current, charged debate about unsustainable health-care costs and the Affordable Care Act, Peter Ubel, Duke University professor of medicine, feels it's time for a cultural shift among doctors. In a New England Journal of Medicine article he wrote with colleagues, Ubel argues that physicians needed to start incorporating the cost of care into their diagnoses.

Ubel emphasizes that patients should know doctors can often provide less expensive alternatives. "No one should have to suffer unnecessarily from the cost of medical care," he wrote. "Simply put, discussing costs in the doctor's office is good medicine."

But doctors don't always know how much a patient will pay. "For the most part, it's very difficult for a doctor to know how much something is going to cost a particular patient," says Kelly Kyanko, a physician at Bellevue Hospital Center in New York City. "The way we calculate out-of-pocket costs is extremely confusing. There are just too many variables in the equation."

Of the many things to consider are deductibles, co-pays, co-insurance, whether a doctor is in or out-of-network, and the list price or negotiable rate of a procedure or treatment.

A 2010 study found that hospitals are often unaware of the cost of care they provide because prices are often established according to a confidential pricing structure that involves contracts between hospitals, insurances, and vendors. In the NEJM piece, Ubel and colleagues noted that "it is very difficult, and often impossible, for the clinician to know the actual out-of-pocket costs for each patient, since costs vary by intervention, insurer, location of care, choice of pharmacy or radiology service, and so on."

Some physicians think talking about costs with a patient is a violation of their relationship. And some of those costs come from being overly cautious - many doctors, especially inexperienced ones, practice "defensive medicine" by ordering multiple tests for their patients despite what they might cost.

According to a 2012 study in Health Services Research, Kyanko says approximately 3 percent of individuals with private health insurance received unwanted out-of-network care, i.e. high out-of-pocket costs. Of the 8,000 participants in the study, 40 percent reported receiving an unexpected bill, which translates to 3 million patients paying an unforeseen share of medical costs nationwide.

"If we can just make prices available to patients, we would solve this problem," Kyanko says. "If you knew going into a doctor's visit that a test was going to cost $400, it would help you in your decision-making."

Kyanko says she has a frank discussion about cost with her uninsured patients. She tells them about how expensive a treatment might be, and asks whether cost might become an issue in her patients' care and whether it will affect their adherence to prescribed regimen. If it might, they jointly try to figure out a way to fix it. "To do it on a case-by-case basis is not a good long-term solution, but a good short-term one," she says.

A systems-based approach to informing doctors and patients about costs seems to be the best solution. At Bellevue, for instance, some exceptionally expensive drugs are marked in the system by a dollar sign. This reminds doctors to consider whether a patient truly needs the treatment or if they are simply erring on the side of caution. "I think this is a much better way to control costs and help patients," says Kyanko, "rather than expecting the patient to go to medical school and figure out the pros and cons of the MRI scan that their doctor is recommending."