Nov. 5, 2009 As health insurers require people to base more treatment decisions on out-of-pocket costs, physicians should learn to talk to patients about money, according to researchers at Wake Forest University School of Medicine.
With health insurance open enrollment season under way -- when tens of thousands of workers learn of increases in their deductibles and other out-of-pocket costs -- the issue is especially timely, said Mark A. Hall, J.D., a professor of law and public health in the Division of Public Health Sciences at the School of Medicine.
"Each year, doctors are finding more and more that patients are coming in carrying substantial deductibles and having to pay more out of pocket," he said.
Co-authored by Carl E. Schneider, J.D., of the University of Michigan at Ann Arbor, a summary of three years' worth of research on the subject,appears in the current issue of the Journal of Family Practice.
Hall said that doctors generally avoid asking patients about health insurance and finances because physicians want what they believe is best for their patients -- and what's best might not always be most affordable.
However, Hall and Schneider say patients are counting on physicians to help guide them to the best treatment decisions -- medically and financially.
The researchers reviewed literature on relevant professional ethics and interviewed primary care physicians who treat lower-income patients to see how the physician-patient relationship is changed by the current trend in consumer-driven health care -- in which patients pay for more treatment themselves and therefore make more cost-related choices.
The physicians described patients who left prescriptions unfilled or refused to get diagnostic treatments because they couldn't afford them. One patient severed a finger in a farming accident, and his primary care physician fixed it -- though he knew a surgeon at a hospital could better ensure limited nerve damage. The patient said he wanted his doctor to treat him -- or would receive no treatment at all.
Hall encouraged patients to bring up financial concerns with their doctors.
"You shouldn't be afraid to talk to doctors about having to pay for things," he said, adding that doctors and patients talking about money is not a new concept. Doctors several generations ago, before employer-sponsored health insurance was standard, hashed out payment with patients daily, he said.
"We have forgotten that aspect of professional folk wisdom," Hall said. "Doctors need to make their treatment recommendations in the context of what patients can and can't afford, with the understanding that some patients can't afford what they might recommend."
Hall said doctors need training on how to effectively talk with patients about money. The experienced physicians interviewed for this study suggested asking patients not about ability to pay, but instead about the extent of the patient's insurance coverage, to avoid the embarrassment some patients feel admitting they can't afford their doctors' bills.
"Normalizing with tone of voice and a matter-of-fact way, the patient picks up that this is not something embarrassing," Hall said. "This is just a fact that the doctor wants to know about."
Moreover, malpractice is of little concern. In previous studies, Hall and Schneider found that such conversations -- and the treatment decisions they result in -- created negligible legal issues for doctors. "If they have an open conversation with a patient who subsequently chooses to take a cheaper route, there's little chance of a lawsuit because the choice is ultimately for the patient, not the doctor, to make," Hall said.
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