Applied Evidence

Professional obligations when patients pay out of pocket

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Here’s what the ethics literature—and real-world experience—teaches us about helping patients make better cost-conscious choices.



During a long-overdue routine check-up with a 65-year-old Caucasian patient we’ll call Dan, you discover his blood pressure is 150/90—this, despite the prescription you wrote for him nearly a year ago. When you recommend that he increase the daily dose and suggest he may want to try a newer drug, he tells you he never filled the original prescription. Soon it’s apparent that he and his wife, who has diabetes, hypercholesterolemia, and severe arthritis, have been deciding which medicines to take and how often to schedule visits based on their monthly budget.

This is one of countless common scenarios playing out as a result of consumer-directed health care (CDHC), the latest movement in the constant struggle to control the costs and improve the quality of health care. CDHC uses mechanisms like steeply tiered co-payments, high deductibles coupled with health savings accounts, and reduced coverage (such as the infamous “donut hole” in Medicare Part D) to compel patients to spend their own money, not insurance money. This approach is intended to give patients more “skin in the game” so that they look harder for thriftier options and accept only treatments they really think are worth the money.1,2

CDHC may be wise; it may be foolish. But many patients must use it, and they urgently need their doctors’ help. This asks a lot of you, but the medical profession has a long and honorable tradition of pursuing what is best for patients, not just what is most cost-effective.3 Patients’ modest understanding of health insurance, providers, and medicine rarely equips them to make medically and financially prudent decisions. For sound information and sage guidance, your patients must rely on you, their physician. In other words, under CDHC, patients present not just with medical symptoms and a social history, but also with a financial condition.

So what kinds of practical and ethical problems does this create? Official oracles of medical ethics are virtually silent, yet patients have paid their own costs from time immemorial, and much can be learned from the collective wisdom of doctors’ accumulated experience.4

With this in mind, we interviewed a convenience sample of 7 primary care physicians in North Carolina who treat lower-income patients (3 in family practice, 2 in geriatrics, 1 in internal medicine, and 1 in pediatrics), and we reviewed the relevant professional ethics literature.5-10 From this body of practical and professional knowledge, we synthesized the following principles and strategies.

Talking about money is fraught with difficulty

If you are to help patients in the new consumerist health care world, you need to know to what extent money is an issue for a patient. But both doctors and patients often dislike discussing money.11,12 In 1 study, women were more uncomfortable talking about their income than their abortion.13 Many patients hesitate to broach the topic for fear of offending their doctor, who recommends services and may be selling them.11,14 And many doctors fear that mentioning costs during examination and treatment will alienate patients who take offense at, or misunderstand the motives behind, discussions of money.11,15

Medical anthropologist Howard Stein even suggests there is a “taboo in official American health culture: namely, a prohibition upon allowing the physician to appear concerned with financial matters” because introducing money violates “the sacred by the profane.”16 Nevertheless, the purpose of CDHC is precisely to place cost in the front of patients’ minds. So patients may be grateful for help in acknowledging the elephant in the room.

Approach finances as forthrightly as you would a potentially embarrassing clinical problem. You can work to help patients feel comfortable discussing costs by treating financial issues in the same matter-of-fact way you address sexual concerns.17 One doctor we interviewed at a low-income clinic said that his patients may be ashamed or embarrassed to acknowledge their financial problems. So he normalizes cost concerns by routinely asking patients if insurance coverage will be an issue—gracefully putting the discussion more in terms of third party rules than the patient’s ability to pay.

Other doctors we interviewed recommend watching for clues patients give when they are concerned about costs, just as doctors attend to patients’ clues about clinical problems.18 Patients may, for example, delay scheduling visits or neglect to fill prescriptions. As a fine doctor said a century ago, “Just remember that people generally care little how you collect your facts. They want to help you to help them, and are ready to accept your methods, especially if tactfully applied.”19

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