Professional obligations when patients pay out of pocket

Patients often feel relieved to address cost problems, but finding out exactly what financial obligations a patient faces can be challenging. Different health plans allocate costs between patient and insurer in dismayingly different ways. Furthermore, those allocations fluctuate depending on each policy’s annual cycle of deductibles and out-of-pocket limits, which in turn depend on each patient’s renewal date. Patients are better situated than doctors to know the particulars of their own plans, but most people find their insurance baffling. Advances in information systems someday will prune this thicket, but today insurance coverage must often be added to the list of concerns about which doctors need better information.

Share your knowledge of treatment costs. If patients who pay out of pocket really are to make wise economic and medical choices, they need to know what tests and treatments cost.²⁰ This information, too, may be elusive. For instance, physicians often are unfamiliar with, or mistaken about, the plethora of drug prices. One literature review reports, “With…the median [physician’s] estimate 243% away from the true cost, many of the estimates appear to be wild guesses.”²¹ And hospital charge masters are impossible to master. They can list more than 40,000 items whose prices are negotiated by insurance companies in a tumultuous market that regards prices as trade secrets.²²

Precision may be unachievable, but there is room at least for a better understanding of large-magnitude cost differences. For instance, physicians we interviewed said that their computers or handheld devices provide basic information about the costs of prescription drugs, and some states and leading insurers are starting to post comparative provider and procedure prices online.²³ Without these aids, doctors still appear very able and practiced in discussing the costs of different options in general qualitative terms, even if they lack exact price information.

How to factor cost into your discussions of treatment

The law of malpractice enforces the medical profession’s minimum standards for treatments, and the culture of medicine expects doctors to provide the best care available—to apply the gold standard of treatment. Patients (and perhaps juries) share that preference. But CDHC gives patients reasons to seek something less than the gold standard.

So once approximate costs are known, how should you factor them into discussions about treatments? When care is needed, do you merely inform the patient of less expensive options but always recommend the optimal one? When might you press a more effective option on a reluctant patient? Once again, these questions raise dilemmas doctors know all too well.^24,25 You face them every day when patients assert other reasons to refuse treatment, like discomfort or inconvenience, or when their reticence amounts to little more than caprice. Here are 3 situations to consider:

When some treatment is better than none at all. The easiest situation arises when a more expensive option would be superior in an ideal world, but not in the real world. Sometimes, the best can be the enemy of the good. For example, if a patient who is offered only the medically optimal treatment leans toward forgoing treatment altogether, doctors often recommend a suboptimal but still useful alternative.²⁶ Based on examples we heard, a physician might order a generic medication to control blood pressure when much costlier options are only moderately more effective, or an x-ray rather than a computed tomography scan, or 1 return visit rather than 2.

But what about malpractice liability for suboptimal care? Within reasonable ranges of professional judgment, the liability threat is not serious, since there are 2 legal defenses:²⁷

1. If a less expensive treatment, or no treatment at all, is within the broad prevailing standard of care or a recognized alternative school of thought, then doctors may recommend this, even if it is not the course they normally counsel.
2. Even substandard options are defensible if reasonably well-informed patients understand their options and reject the doctor’s first recommendation.

When medical consequences of refusing a treatment are not dire. A second situation is also comparatively easy, at least in theory. Where the long-term medical outcomes are not dire and patients experience the health consequences directly, patients can reasonably be left to make suboptimal choices. Examples we were given include physical therapy or pain control. When a patient is considering direct-impact, lower-stakes treatments, a doctor should not feel great ethical or liability qualms in acceding to the patient’s wish to sacrifice health for wealth.

When a patient’s decision and your opinion are at odds. In the third category, physicians’ role as healers conflicts with their role as patients’ agents.^28,29 If you suspect that a cost-reluctant patient can afford the gold standard and the patient chooses the pyrite standard, what should—or may—you do? This, too, is a variant of a familiar problem: Even well-informed patients may make bad decisions. To cope, doctors have developed an array of techniques (from soft to firm) that can be applied when decisions seem “penny wise and pound foolish.”³⁰