A surgeon ethicist asks that physicians sometimes stop to consider how the cost of their services affect patients. There’s a term for this: financial toxicity.
“Financial toxicity is the financial burden or stress patients endure in response to the cost of their treatment or care in the healthcare system,” says Catherine J. Hunter, MD, FACS, associate professor of surgery at Northwestern University Feinberg School of Medicine. Hunter was enlisted to speak about financial toxicity for an ethics colloquium on money and modern surgical practice at October’s American College of Surgeons’ Clinical Congress 2018. “We need to be mindful that what we recommend for our patients has a financial impact on them and their families.”
Included in financial toxicity are a patient’s out-of-pocket expenses, deductibles, copays, and cost of health insurance.
“A person has objective and subjective financial concerns, and those lead to financial toxicity,” Hunter says. “Stress can impair patient outcomes. Sometimes, [patients are] so stressed about the loss of finances and how they can’t afford to live that it makes them ill. Other times, they cut corners or skip treatment or don’t pick up pills.”
Surgeons might consider whether it is the provider’s responsibility to tailor or modify their patients’ workup or care to consider what patients can actually afford, Hunter suggests.
“I don’t routinely ask all my patients what their financial status is, but I also think we should come up with a plan of care that’s not overly burdensome for a patient to complete,” she says. “If you make a plan of care, even if it’s a good plan of care, and it’s not one a patient can successfully complete, then you’re not doing the patient any favors.”
Physicians also should be mindful of some of the tests they order for patients. “If a test has been done previously, then don’t reorder it. If we can use simpler, less expensive tests to get similar diagnostic information, then we should do that,” Hunter explains.
The key is to be mindful of what the patient can afford and really needs. “I sometimes see patients referred to me — a pediatric surgeon — for a workup of a hernia, and the provider did some imaging, an ultrasound or CT scan,” Hunter says. “That’s not necessary for my population. A physical exam is enough, rather than having people pay for additional imaging if they don’t need it.”
Healthcare providers also should reconsider prescribing expensive medication when existing options would work.
“From an ambulatory surgery care standpoint, physicians could try to provide some clarity for patients and transparency regarding costs,” Hunter says. “Maybe patients could have some input. The physician could say, ‘If we do this particular test, it would be potentially helpful, but this is the cost of this test versus that one.’”
It is possible to measure financial toxicity as a patient-reported outcome. In 2017, researchers developed the COmprehensive Score for financial Toxicity (COST) to better understand cancer patients’ characteristics, clinical trial participation, healthcare use, willingness to discuss costs, psychological distress, mood states, and quality of life.1 COST questions ask patients about whether their out-of-pocket medical expenses were more than they expected. Also, COST queries patients to say whether they agree with a statement about how they have no choice in how much money they spend on care, Hunter explains.
While most of the research on financial toxicity has focused on cancer patients, medical ethicists and others are beginning to understand that financial toxicity is applicable to many other areas of medicine. “Healthcare costs are not always transparent,” Hunter says. “If you go to a hair salon, you could look on their website and see what they charge for a particular style and treatment. Some centers offer that level of information, but it’s not across the board.”
Patients might never be told the total cost of their surgery, and they could be uncomfortable telling their doctors that they are scared from a financial standpoint. Physicians might be uncomfortable asking patients if they can afford a procedure.
“One of the main things that causes stress for people is when they can’t anticipate what they’re getting themselves into. It’s that feeling of a lack of control over their financial situation when they find out their expenses are more than they anticipated,” Hunter says.
It would be helpful for ASC staff to review a list of costs with the patient to fully show the extent of their financial burden, Hunter offers. “[Direct] a point-of-service individual [to] cover that information as part of the visit.”
- de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the COmprehensive Score for financial Toxicity (COST). Cancer 2017;123:476-484.