Ethical responses when cost of care becomes the issue
Many providers uncomfortable discussing cost
It's no longer just the patient and the doctor in the examination room, says Michele Meltzer, MD, MBE, clinical associate professor of medicine at Thomas Jefferson University in Philadelphia, PA.
"You have the payer — insurance company or government — and society as a whole, in addition to the patient and physician, as stakeholders in the office," she says. "We don't talk about that nearly enough."
Concerns about the cost of health care are increasingly becoming part of the patient-physician relationship. "It may not be just paying for the visit. It may be paying for the copay," says Meltzer. "There are no guidelines for providers on what to do in this situation. Many of us are just beside ourselves."
"Slow adoption" of knowledge on costs
Conversations about costs are more likely to happen, given continuing focus on the implementation of the Affordable Care Act and pharmaceutical pricing in the United States, according to John Henning Schumann, MD, Gussman/Adelson chair in internal medicine and program director of internal medicine residency at University of Oklahoma School of Community Medicine in Tulsa.
"Many physicians are not comfortable discussing these issues, mostly out of the profession's slow adoption of knowledge about costs," he says.
Medical education has primarily focused on the most effective and appropriate diagnostic pathways and treatments, with little or no regard to costs. "But that simply is no longer the case," he says. "If one is to practice 'sound' medicine, taking the patient's likely adherence into account has become the norm."
Survey data show that patients want doctors to take costs into consideration when recommending treatments, and that doctors are increasingly aware of the importance of out-of-pocket costs to patients as part of the calculus of adherence.1,2
"Some physicians have argued that the ethical imperative is to provide the best treatment recommendations regardless of cost," says Schumann. "But that position ignores reality."
Providers "bending" ethical standards
More than one-half (51%) of 771 rheumatologists who responded to a 2013 survey said they grapple with the high cost of treatment for their patients.3 Physicians reported ways in which they see themselves as "bending" ethical standards, and presented their justifications for doing so.
Examples included "embellishment" of symptoms to help patients obtain prior authorization from insurance companies; stretching the truth to obtain needed drugs and testing for patients; and providing patients with certain diagnoses to obtain coverage for needed medications or physical therapy.
"The number one issue that we found was the societal costs of expensive medications and profits from infusions," says Meltzer, one of the study's authors.
While there is a great deal of focus on transparency in health care, patients, and even providers, are often unaware of the cost of care. "Even if a patient's copay is high, they still may not grasp what their medications actually cost a month," she says. "Most of the time, the patient is insulated from the complete cost."
A 2014 study asked 503 orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of 13 commonly used orthopedic devices.4 Attending physicians correctly estimated the cost just 21% of the time, and residents were able to do so 17% of the time. However, more than 80% of respondents indicated that cost should be "moderately," "very," or "extremely" important in the device selection process.
"As physicians, we are often unaware of the costs of what we are ordering," says Meltzer. "We should take that into account, all things being equal."
Physicians may over-order costly tests because of liability risks, or because patients demand a particular test. "With time constraints, it's sometimes just easier to take the path of least resistance," Meltzer says.
There is a need to compare and contrast newer therapies with older ones and do a cost-effectiveness analysis, she urges.
"For example, febuxostat, a drug used to treat gout, was released in 2009. It costs substantially more than allopurinol, an older generic drug," says Meltzer. Both drugs lower serum uric acid, which causes gout, but the analysis of the effectiveness of older drugs may be obscured by the way some clinical trials are set up.
Discussion over the cost of care, says Meltzer, "needs to be the venue of the public press, the medical press, and our professional meetings."
Guidelines often ignore cost
There is an ongoing debate as to whether treatment guidelines, whether from an insurance company or a professional society, should take cost into account.
The American College of Rheumatology's guidelines discuss different agents to treat gout without addressing cost. "For first-line therapy, there are two drugs that are vastly different in price. They didn't make a distinction that you should start with the less expensive one first," Meltzer notes. In contrast, a similar set of guidelines from England's National Institute for Clinical Effectiveness recommend that the less costly drug be used first because it is equally effective.5
A very costly drug may allow a patient to continue working, however, or a less expensive drug might require extensive monitoring.
"You have to look at the total picture," says Meltzer. "But we need to be transparent about what things actually cost, and who is paying for it."
- Alexander GC, Casalino LP, Meltzer DO. Physician strategies to reduce patients' out-of-pocket prescription costs. Arch Intern Med 2005; 165(6):633-636.
- Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003; 290(7):953-958.
- MacKenzie CR, Meltzer M, Kitsis, EA, et al. Ethical challenges in rheumatology: A survey of the American College of Rheumatology membership. Arthritis & Rheumatism 2013;65: 25242532.
- Okike K, O'Toole RV, Pollak AN, et al. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Affairs 2014; 33(1):103-109.
- Meltzer M, Pizzi LT, Jutkowitz E. Payer decision-making with limited comparative and cost effectiveness data: The case of new pharmacological treatments for gout. Evid Based Med 2012; 17(4):105-108.
- Michele Meltzer, MD, MBA, Clinical Associate Professor of Medicine, Jefferson Medical College, Philadelphia, PA. Phone: (215) 955-1410. E-mail: Michele.Meltzer@jefferson.edu.
- John Henning Schumann, MD, Gussman/Adelson Chair in Internal Medicine/Program Director, Internal Medicine Residency, University of Oklahoma School of Community Medicine, Tulsa. Phone: (918) 660-3456. E-mail: firstname.lastname@example.org.