Doctor, how much will this cost?

When I was young, newly married, and in graduate school, I needed to have some wisdom teeth extracted. I went to a dentist near my home, and he took x-rays and explained what all needed to be done for the extraction. I had little money at the time and I asked, necessarily, how much it would all cost. He gave an exasperated sigh and told me we’d talk about that later. We wouldn’t, because I asked for my x-rays and left without scheduling the extraction.

Through family, I managed to find a dentist who was willing to do the extraction for a set Stethoscopeprice with the caveat that one always runs the risk of unexpected and unavoidable complications running up the costs. In the latter event, this dentist, knowing my family, agreed to work on a reasonable repayment plan. The extraction went well, I was able to pay for it, and we all went on about our business.

The remarkable part of this story is that I never again had a frank discussion with any healthcare provider regarding the cost of treatment, though I have often been shocked by the prices of tests, prescriptions, and other services.

Ideally, I think when doctors (or other providers) tell patients about a treatment’s risks, side effects, and benefits they should also talk about the treatment’s cost and whether there are cheaper alternatives. Sometimes, a cheaper alternative is just as efficacious as the expensive choice the doctor is prescribing. In this way, discussions of cost can be woven seamlessly into the informed consent process.

Of course, adding a discussion of price to the informed consent process will add another burden for doctors, who are already feeling pressured for time. In a column in the New York Times, cardiologist Sandeep Jauhar points out that reduced payments to doctors have forced doctors to take on more patients to maintain their income. As a result, doctors spend even less time talking to patients and feel even more rushed to move on to the next patient. Adding a discussion of cost to informed consent will only create more pressure for the doctor to hurry through each patient encounter.

Further, it is difficult for doctors to inform patients of something they don’t know themselves, and doctors are frequently unaware of the cost of medications and other services they prescribe or order. A 2007 paper by G. Michael Allan, Joel Lexchin, and Natasha Wiebe found that “Physicians’ awareness of the cost of therapeutics is poor. With only 31% of estimates within 20% or 25% of the true drug cost and the median estimate 243% away from the true cost, many of the estimates appear to be wild guesses.” If physicians knew the cost of their prescriptions, they might prescribe differently in many cases, so it would be a huge step forward if both physicians and patients could be better informed about healthcare prices.

Physician Peter Ubel wrote a blog post about his experience with getting a prescription from his own doctor that was $200, much more than he had anticipated. When Ubel spoke with his doctor, the prescribing physician admitted he had no idea the prescription would cost so much. Ubel asks whether we should expect doctors to research costs before prescribing. It may be too much of a burden to ask doctors to do more research, but this may be a case where the move to electronic health records (EHRs) may benefit patients directly.

If an EHR retains patient insurance information, then it should be able to calculate the cost of any treatment stored in database and automatically display it to the doctor when the prescription is entered. With a really expansive system, it might even show the cost of alternative treatments. The doctor could then easily present the patient with each treatment and its cost.

I have serious reservations about the growth of EHRs and massive databases of personal information that is not easily controlled or limited; however, if we have EHRs anyway, we might as well use them to save money for patients. In the meantime, I think we will all do well to bring up the issue of cost with healthcare providers at every available opportunity. By doing so, we will make our providers aware that cost is an important consideration in prescribing, and we may also slowly work our way toward much greater transparency.

 

It is Time to Shed Sunshine on Informed Consent

Most patients realize doctors receive gifts from the pharmaceutical and device-

A patient having his blood pressure taken by a...
A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

manufacturing industry. When we see industry logos on pens, clocks and posters, we don’t assume the doctors ordered these items from the merch page of these companies, but most of us aren’t aware of how lucrative the payments to doctors can be.

A story that ran in the New York Times described the experience of Dr. Alfred J. Tria, who made $940,857 in about two years for promoting products and training doctors in Asia to use them. The article notes that Tria’s experience may be exceptional, but in two and a half years, industry paid out $76 million to doctors practicing in Massachusetts alone.  I’ve been reading about this subject for a while, and even I was surprised that someone could make half a million dollars in a year on a side job.

In a slightly different type of payout, Oregon recently concluded a court case against two doctors who “put heart implants into patients without telling them that a manufacturer’s training program put a sales representative into the operating room.” The doctors would receive between $400 and $1,250 each time they completed a surgery using Biotronik defibrillators and pacemakers. The state argued that patients should know when doctors’ recommendations may not be based entirely on the needs of the patient. One of the doctors in the case earned more than $131,000 from 2007 to 2011 through implant surgeries. Doctors also received speaking fees, expensive meals, and other gifts.

As part of the Affordable Care Act (Obamacare), the Sunshine Act now requires industry to start collecting data on payments to doctors now, and the information will be made available to the public next year on a government website. This will enable patients to learn how much their doctor receives from the industry each year, though there may still be hidden incentives.

For example, doctors may be in profit-sharing arrangements with facilities or they may actually be the owners of the facility. A recent study by Dr. Matthew Lungren found that doctors who had a financial stake at an imaging facility ordered tests with negative results at a much higher rate (33 percent) than doctors with no financial stake. In other words, it appears that doctors order unneeded tests because they are making money off of them, not because the patients need them. Lundgren suggests that patients should ask whether they are being referred to a facility in which the doctor has a financial stake. I say the doctor should volunteer the information.

Beginning next year, the Sunshine Act will make it much easier for patients to discover their doctors’ financial relationships with industry, and I’m thrilled for this development. For those who think Obamacare is a complete disaster, just take a minute to relish this one positive development.  Still, I think the movement should go further. I think financial disclosure should be part of the informed consent process. When your doctor is telling you all the risks and benefits of treatment, I think he or she should also say, “I get paid $1,000 to do this surgery,” “I will make $100 off this MRI,” or “I own stock in the company conducting this medical research.”

I believe patients want this information, and I don’t think they feel it is their responsibility to search for it. True informed consent is only possible in light of complete financial disclosure.