Authors: Be sensitive to patient ability to pay

Doctors can assist when patients self-pay

With the advent of consumer-directed health care (CDHC), two professors argue, contrary to the common notion that physicians should ignore financial considerations when treating patients, that it is entirely appropriate for physicians to be sensitive to a patient's financial position when a patient is paying out of pocket. In fact, what most ails the patient may be his or her financial ability to pay for optimal health care services.

That is the message Mark Hall, JD, Fred D. & Elizabeth L. Turnage professor of law & public health and director, Center for Bioethics, Health & Society, Wake Forest University, Winston-Salem, NC, conveys in an article he co-authored titled "Professional obligations when patients pay out of pocket." The article was published in The Journal of Family Practice in November and co-authored by Carl E. Schneider, Chauncey Stillman professor of law and professor of internal medicine, University of Michigan in Ann Arbor.1

"Patients' modest understanding of health insurance, providers, and medicine rarely equips them to make medically and financially prudent decisions," the authors write.1 "For sound information and sage guidance, your patients must rely on you, their physicians. In other words, under CDHC, patients present not just with medical symptoms and a social history, but also with a financial condition."

Self-paying patients are not new to medicine, as that is how the practice of medicine began before the advent of health insurance, Hall notes.

"It's only been in the last 50 years that money has sort of receded, as insurance became more comprehensive and more widespread, first for hospitalization and then for physician fees," Hall says. "Physicians have had the luxury of the last several decades [of] just assuming most patients had pretty good coverage."

Traditionally, family doctors may have known their patients and their family and financial situations so well that they could recommend the best course of action to those patients without directly addressing finances.

"In the past, a hundred years ago, they did that," Hall tells Medical Ethics Advisor. "In the classic situation, the doctor delivered the baby and knew the parents and knew everything about the family — some even made house calls . . . and so they understood what the family could afford and what they couldn't, and could adapt their recommendations accordingly. [Money] wasn't put front and center, in that it wasn't negotiated, but it was just that the doctor made informed decisions about what made sense under the circumstances and then would send periodic bills and collect them — and sometimes not," Hall explains.

Hall maintains that the CDHC movement started even before the current economic downturn, in which so many have lost health insurance.

"It's really a reaction — a backlash to the concept of managed care and the idea that people didn't want insurance companies telling them what [they would pay for and what they wouldn't pay for]," he explains.

"But physicians had adapted their practice styles based on their assumption that most patients had insurance coverage. And they practiced historically in a way that they would do what is best for the patient, "and somehow the bill would get paid, and for the percentage that didn't pay, well, that's just professional obligation," he says.

"But now, we're looking at a situation where for many patients, or perhaps for most, at least in a primary care setting, and especially in a referral setting, those understandings are beginning to return to the old days, where patients pay a good portion, or the entire portion of the bill," Hall says.

Strategies to approach the topic

In the article, Hall and Schneider note that if physicians are to help their self-pay patients, they "need to know to what extent money is an issue for patient." That means somehow addressing the topic of money and ability to pay with the patient.

"But both doctors and patients often dislike discussing money," the authors write.1

Still, they write, "patients may be grateful for help in acknowledging the elephant in the room."

The authors suggest that physicians, therefore, "approach finances as forthrightly as you would a potentially embarrassing clinical problem."1

Some of the physicians interviewed for the article suggested that physicians "watch for clues patients give" about their financial situation, just as they would when patients provide clues to their health situation.1

"One doctor we interviewed at a low-income clinic said that his patients may be ashamed or embarrassed to acknowledge their financial problems," the authors write.

The authors also encourage physicians to "share your knowledge of treatment costs" to help the patient with decision-making.


  1. Hall, Mark A. Schneider, Carl E. "Professional obligations when patients pay out of pocket." The Journal of Family Practice. Vol. 58. No. 11, November 2009.


  • Mark Hall, JD, Fred D. & Elizabeth L. Turnage professor of law & public health and director, Center for Bioethics, Health & Society, Wake Forest University, Winston-Salem, NC. E-mail: